Music Therapy Form Music Therapy Inquiry "*" indicates required fields Name of Client* First Last Person Completing the Form First Last PronounsRelationship to clientClient's Date of Birth* MM slash DD slash YYYY Contact Phone*Contact Email Address*Age of StudentInterest Private Music Therapy Group Music Therapy Private Piano Lesson How client communicates?Parent desired goals of Music TherapyPrevious Music Therapy experiencePrevious music experienceNon-musical interests/hobbies of the childHolidays celebrated (Ex. Halloween, Hanukkah, Christmas, etc.)Family life: (Any siblings? Pets? etc.)Possible Reason(s) for referral*If the client is completing the form independently, leave rows blank that are not applicable. *Any responses that you feel are not relevant to the client can be left blank or write N/A. To strengthen motor skills To strengthen cognitive skills To strengthen social skills To strengthen oral/verbal skills Anxiety and stress reduction Emotional regulation To increase musicality Other If you responded "other", list reasons for referral here:Other Current Therapies: Occupational Therapy Speech Therapy Physical Therapy Other If you responded "other", please name them here:How does the client show they are upset/distressed?Does the client have any allergies?Has the client ever displayed aggression towards people or property?Are there any safety precautions the Music Therapist should know of to facilitate a safe environment for both parties?Any comments or questions?CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ