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Client Intake Form
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* Indicates required question
Email
*
Your email
Phone Number
*
Your answer
Parent Name
*
Your answer
Client Name
*
Your answer
Person Referring
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Your answer
How did you hear about The Treble Makers Music Therapy?
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Your answer
Client's Date of Birth
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MM
/
DD
/
YYYY
Diagnosis if known
*
Your answer
Allergies/Intolerances
*
Your answer
Describe the client's current challenges, issues, or concerns that have led to the referral for music therapy.
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Your answer
Reason for Referral
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Behavioral needs
Sensory needs
Executive function
Gross motor skills
Fine motor skills
Social skills
Emotional regulation
Increased self-esteem
Attention
Communication
Academic skills
Required
Describe the client's past and current involvement with music (e.g., playing instruments, singing, listening habits).
*
Your answer
Other therapies and community programs
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Your answer
Has the client received music therapy previously?
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Yes
No
Cultural or religious considerations related to music therapy services?
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Your answer
Goals/Expectations in Music Therapy
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Your answer
Comfort level with group versus Individual Session?
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Your answer
Education
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Home Schooled
Public/Private School
Adult Services
Available Appointments
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Monday 10:30- Jessica
Tuesdays 11:30-Jessica
Fridays 11:00- Jessica
Waiting List
Required
Please sign the confidentiality agreement and any other contracts upon arrival
*
Yes
No
Questions/Concerns
*
Your answer
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