Music Therapy Pre-Assessment Form 
A brief set of questions to prepare for your initial online consultation 
Full name of individual being referred for Music Therapy
 *
Date of Birth of individual being referred for Music Therapy
 *
MM
/
DD
/
YYYY
Emergency Contact Name & Number
 *
Name of Local Authority

(For children & young people) What nursery/school/college/university does the individual attend? 

What is the primary reason for your referral to Music Therapy? 
What professional support (if any) is currently in place for the referred individual? How are they responding to this support? 
Are there any concerns around self-harm, self-injurious behaviour or suicidal ideation for the referred individual? 
 *
How would you plan to fund Music Therapy sessions? 
Clear selection
What days and times could you come to sessions? 
What would be the best location for you? 
Clear selection
What questions would you most like to ask me in our initial consultation? 
Submit
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