Music Therapy Services

Client Name *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Client Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Diagnosis *

Please select all which apply.

None/Unknown

Autism Spectrum Disorder

Attention Deficit Hyperactivity Disorder

Cerebral palsy

Down's syndrome

Brain injury

OTHER, please list below.

Guardian Name *

First Name

Last Name

Guardian Address, if different from client's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Communication Strategies *

Please select all which apply.

Reliably speaking/No alternative communication needed

Facilitated Communication

Rapid Prompt Method

Choice boards

OTHER, please list below

For client's who utilize alternative communication, please select from below which best describes your level of comfort.

Yes, I'm comfortable with therapist physically supporting client when using communication devices.

No, I would prefer therapist to not physically support client when using communication devices.

Sensory Sensitivities *

None/Unknown

Loud sounds

Touch

Smells

OTHER, please list below.