Florida Music Therapy Intake Form
Hi there!
Before starting services, an intake form is required for all participants. By continuing to fill out this page, you are acknowledging that your confidential health information can be viewed and stored within HIPAA secure Google Forms. If you have any questions or concerns about our privacy policy, please email Info@FloridaMusicTherapy.com to request a printable intake form.
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Email *
Today's Date *
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Name of person completing form, and relationship to participant (mark self, if self reporting) *
Would you like to join our email list? *
Participant Information
Please tell us a bit about the participant signing up for music therapy.
Participant's First and Last Name *
Birthdate of Participant *
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Gender
Phone Number *
Address *
City *
State *
Zip Code *
Emergency Contact Name and Relation *
Emergency Contact Phone Number *
Diagnostic/Medical Information
Your answers to these questions will help us better prepare for music therapy sessions.
Diagnoses, if any *
Medications, if any *
General Medical: Does the participant currently have or previously had any of the following: (if none, check 'none.') *
Required
Motor Skills: Does the participant currently have or previously had any of the following? (If none, check 'none.') *
Required
Sensory: Does the participant currently have or previously had any of the following? (If none, check 'none.') *
Required
Communication/Language: Does the participant currently have or previously had any of the following? (If none, check 'none.') *
Required
Cognitive: Does the participant currently have or previously had any of the following? (if none, check 'none.') *
Required
Social/Emotional/Mental Wellness: Does the participant currently have or previously had any of the following? (if none, check 'none.') *
Required
Scheduling and Session Preferences
What type of music therapy session are of interest? *
Required
Music therapist gender preference *
What type of session are you interested in?  Please choose all that apply *
Required
When are you available for music therapy sessions? (Please check ALL availabilities)
Mornings 9AM - 12PM
Afternoons (12PM-4PM
Early Evenings (4PM-7PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (Only available in Brevard County)
Though we can't guarantee availability, what is your preferred date/time?
(I.e. my kids get out of school at 4pm, 
so 4:15 in home or 4:30 in studio on Mondays or Wednesdays)
Accessibility needs, if any
Current therapies, if any
Past therapies, if any
Please describe the participant's musical experiences (NOTE: No musical skills or experience is required for any music therapy sessions.)
Please describe the participant's musical preferences
What goals or outcomes do you hope to obtain from music therapy? *
What would you like your music therapist to know?
How did you hear about us? *
Please list your referral's name, if we may thank them for recommending us
Let's talk about funding.
Payment Methods / Funding Sources *
For Gardiner / FES Only: Student ID Number:
For CMS / Sunshine Health Only: Insurance ID Number
For Simply Healthcare Only: Insurance ID Number
Current Physician's First and Last Name *
Current Physician's Phone Number *
Current Physician's Fax Number *
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