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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