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Music Therapy Intake Form: Minor
Questions on this form are for the purpose of collecting information in order to develop an individualized music therapy program to meet your child's needs. Information is confidential.
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Client Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender & Pronouns
Your answer
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
Dominant Hand
Left-handed
Right-handed
Ambidextrous
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Parent/Guardian Name
*
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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