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Music Therapy Intake Form
Questions on this form are for the purpose of collecting information in order to develop an individualized music therapy program to meet your family member's needs. Information is confidential.
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Email
*
Your email
Client Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Ethnicity
*
White (not of Hispanic origin)
Latino or Hispanic
African American or Black (not of Hispanic origin)
Asian or Pacific Islander
American Indian or Alaskan Native
Other
Gender & Pronouns:
Your answer
Dominant Hand
Left-handed
Right-handed
Ambidextrous
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POA/Guardian Name:
*
Your answer
Relationship to client?
*
Your answer
Preferred method of communication
Email
Phone call
Other:
Phone Number
*
Your answer
Email address
*
Your answer
Mailing address
Your answer
Emergency Contact: Name
*
Your answer
Emergency Contact: Phone number
*
Your answer
Emergency Contact: Relationship
Your answer
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