Name *

First Name

Last Name

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best contact method *

Email

Phone

Text

Emergency contact one *

First Name

Last Name

Phone *

(###)

###

####

Emergency contact two *

First Name

Last Name

Phone *

(###)

###

####

Emergency contact three

First Name

Last Name

Phone

(###)

###

####

Has the client received music therapy before? *

Yes

No

Has the client taken music lessons before? *

Yes

No

Does the client attend school? *

Yes

No

Does the client have a group of friends? *

Yes

No

Does the client interact well on a one-to-one basis? *

Yes

No

Does the client interact well in group activities? *

Yes

No

Is the client colorblind?

Yes

No

Does the client match colors?

Yes

No

Does the client use one-to-one correspondence when counting? *

Yes

No

Does the client identify and label numbers?

Yes

No

Does the client read? *

Yes

No

Does the client write independently? *

Yes

No

Which is the client's dominant hand? *

Left

Right

Unknown

Does the client use a visual schedule? *

Yes

No

What is the client's ability to follow directions INDEPENDENTLY? *

One-step directions

Two-step directions

Three-step directions

Multi-step/Complex directions

Does the client display emotions appropriately? *

Yes

No

Does the client act out, tantrum, or become easily angered? *

Yes

No

Is the client verbal? *

Yes

No

Do others easily understand the client's speech? *

Option 1

Option 2

Does the client speak in complete sentences? *

Yes

No

Does the client ask questions? *

Yes

No

Does the client answer questions? *

Yes

No

Does the client make independent comments? *

Yes

No

Does the client engage in back-and-forth conversation? *

Yes

No

Does the client frequently drop items or have difficulty holding onto items? *

Yes

No

Has the client been diagnosed with high or low muscle tone? *

Yes

No

Has the client been diagnosed with any degree of vision loss? *

Yes

No

Has the client been diagnosed with any degree of hearing loss? *

Yes

No

Are there any instruments in which the client has shown particular interest? *

None

Piano

Guitar

Ukulele

Drums

Other

How does the client respond to music? *

Sing

Dance

Move

Play

Other

These boxes must be checked in order to consent for, and begin, music therapy treatment. *

By checking this box, I confirm that I understand that a parent or guardian must remain on premises for the duration of the music therapy session.

By checking this box, I consent for the client to be treated by Lydia Negron, MT-BC. I consent to care and treatment that falls under the scope of music therapy.

By checking this box, I acknowledge that, while all precautions will be taken, there is always a risk of injury with any therapy involving physical activities. I hereby release Lydia Negron, MT-BC, and any agents, assignors, or assignees, from any claims or damages related to physical movement during the course of music therapy.

By checking this box, I acknowledge that there is a required 24-hour notice to cancel or reschedule a session. We know that sickness occurs; therefore, if you think you are sick the night before, please notify Lydia Negron, MT-BC, directly, so that appropriate plans can be made. Cancellations or reschedules that occur less than 24 hours in advance will incur a $25 fee, due before the client's next scheduled session. If the client misses three consecutive sessions, Lydia Negron, MT-BC, reserves the right to discontinue services.

Name *

First Name

Last Name

Today’s Date

MM

DD

YYYY