Client Referral Form for Circle of Song Music Therapy, LLC 
Thank you for your interest in music therapy services for your child or client through Jefferson, Rock, or Walworth County Children's Long-Term Support Waiver Program. I am grateful for the opportunity to serve each child and family. Please complete this form to make a referral for music therapy services. Please note that most services are currently provided in-office in Whitewater. After I receive this referral form, I will follow-up with the family and caseworker and discuss the best treatment plan and location. 

Yours in music and wellness,

Noelle Larson, Music Therapist-Board Certified 
Director, Circle of Song Music Therapy, LLC 
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Child's Name with Middle Initial: *
Child's Gender:
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Child's Birthday *
Child's Diagnosis/Diagnoses *
Caregiver Name:  *
Caregiver Email *
Caregiver Phone Number: *
Does this caregiver have any communication difficulties that you are aware of?
If yes, are there any accommodations this caregiver needs in order to communicate with me about music therapy services for their child? Ex: email rather than phone call, so they can use Google Translate. 
Which county provides CLTS benefits for this child?  *
City/town where the child resides:
What goals would you like to address through music therapy? *
Is the child able to receive services in-office at the Whitewater Circle of Song Office: 834 E Milwaukee Street Whitewater, WI 53190? 
Name of Caseworker *
Email of Caseworker
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