Music Therapy Assessment Profile
Enrollee Date of Birth
MM
/
DD
/
YYYY
Gender
Name of Enrollee
(First & Last)
Your answer
School Grade Level
(if applicable)
Your answer
Name of Parents
Your answer
Phone Number
Your answer
Email Address
Your answer
Who will be bringing the child to therapy?
Your answer
Relationship to Child
(if other than parent)
Your answer
Phone Number
(if different from listed above)
Your answer
Client Information
Please note: Questions on this form are of a personal and confidential nature. Information will be used by the Music Therapy team only. Details are encouraged, but not required.
Does the client have a current diagnosis?
Details of current diagnosis:
Your answer
Does the client have any allergies or sensitivities?
Details:
Your answer
Are there any precautions that should be taken when working with this child?
(i.e. seizures, biting, self-injurious behavior, etc.)
List here:
Your answer
Does the child participate in any other therapies you would like to share?
List here:
Your answer
Has the child had any previous experience with music therapy?
Details:
Your answer
Have you noticed the child to have any particular musical preference?
(i.e. favorite song, instrument interest, television programs etc.)
Details:
Your answer
Is the child fully ambulatory?
Does the child require any physical assistance?
Details:
Your answer
Does the child have full use of all of his/her limbs?
Details:
Your answer
Have you noticed the child has any fine motor difficulties?
Details:
Your answer
Does the child frequently drop items or have difficulty holding onto items?
Details:
Your answer
Have you noticed the child has any sensory issues?
Details:
Your answer
Does the child resist physical support?
Details:
Your answer
Has the child been diagnosed with any hearing difficulties?
Details:
Your answer
Does the child react or respond to what is being said to him/her?
Details:
Your answer
Does the child follow one-step directions such as “sit down”, “wave”, “close door” etc.?
Details:
Your answer
Does the child communicate verbally?
Details:
Your answer
Does the child have an IEP (Individualized Education Plan)?
Details:
Your answer
Have you noticed the child has any emotional difficulties?
Details:
Your answer
Does the child have any social difficulties related to peers?
Details:
Your answer
Does the child participate in conversation or play with peers/adults?
Details:
Your answer
Is it difficult for the child to be away from parent(s)/guardian?
Details:
Your answer
What would you say are the child’s most prominent strengths?
(Can include particular interests.)
Your answer
What areas do you most hope to see improved through the child’s participation in music therapy?
Your answer
Is there anything that has not yet been covered that you feel is important to share?
Your answer
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