Today's Date:
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Today M-D-Y
County of residence:
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Name (Last, First, Middle):
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Date of birth:
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Current Age:
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Address:
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Primary contact phone number:
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Gender identity:
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Male
Female
Transgender Male
Transgender Female
Binary/Gender Non-Conforming
Prefer not to say
Other
Personal pronouns (check all that apply)
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she/her/hers
he/him/his
they/them/theirs
other
Race:
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American Indian/Alaska Native
Asian
Black
White
Native Hawaiian/Pacific Islander
Multi-Racial
Other
Ethnicity:
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Hispanic/Latino/Spanish Origin
NOT Hispanic/Latino/Spanish Origin
Primary language(s) spoken at home:
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Spiritual beliefs (including food restrictions):
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Holidays celebrated (including secular, like Halloween):
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Person Filling out Form:
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Primary email:
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Relationship to person being referred:
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Person being referred lives with:
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biological parent(s)
adoptive family
other relative(s)
foster family
spouse/partner
Siblings in the home, ages:
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Other residents in the home, and relationship to person being referred:
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Secondary contact:
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Phone number:
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Primary Care Physician:
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Physician contact number:
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Referred by:
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What do you want to address in music therapy? (check all that apply):
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Describe what you'd also like to address in music therapy:
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What is your favorite type(s) of music?
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Who is your favorite singer(s) or group(s)?
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What are your favorite songs?
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What do you like about music?
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What is your preference for music volume (how loud or soft music is)?
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What is your preferred musical activity? (check all that apply)
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Are you interested in any of the following instruments? (check all that apply)
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Do you have any previous music experience (lessons, ensembles, performances, etc.)?
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Yes
No
What do you hope to gain from music therapy?
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Medical diagnoses:
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Other characteristics or symptoms (if no diagnosis):
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Family medical history information:
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Current medications:
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Are you currently in any other therapies? If not, type "no".
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Do you use assistive technology? If not, type "no".
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Do you use any of the following? (check all that apply):
Can you hold your head up independently?
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Yes
No
Can you sit independently?
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Yes
No
Can you stand independently?
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Yes
No
If you cannot stand independently, can you stand with assistance?
Yes
No
Can you walk independently?
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Yes
No
Do you have issues interacting positively with peers, family, or authority figures?
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Yes
No
What are your hobbies and special interests?
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Do you have difficulty expressing or handling emotions?
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Yes
No
Yes
No
How do you express emotions?
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Have you experienced trauma or recent life changes?
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Yes
No
If yes, please describe:
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How do you communicate best? (check all that apply):
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Do you have difficulty paying attention?
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Yes
No
Do you have difficulty remembering things?
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Yes
No
Do you have difficulty with planning or organizing?
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Yes
No
Can you read?
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Yes
No
What is your favorite book(s)?
Do you currently attend school or a vocational program?
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Yes
No
Do you have an Individualized Education Plan (IEP)?
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Yes
No
What is your current school setting?
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Do you use glasses/contact lenses?
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Yes
No
Do you use a mobility aid (cane, guide animal, etc.)?
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Yes
No
Do you use Braille?
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Yes
No
Do you use hearing aids?
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Yes
No
Do you have a cochlear implant?
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Yes
No
Do you participate in any other Center for Excellence in Disabilities services?
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Yes
No
If yes, which one(s)?
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If yes, what supports do you need?
Yes
No
Describe any recent changes or stresses in the family:
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Additional information you would like to share before your visit:
Our family prefers to communicate:
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via phone/standard mail
via email
Our family has internet access:
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Yes
No
I understand clinic is student-friendly and may include participation of student clinicians:
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Yes
No
I understand clinic may be video and/or audio-recorded for educational purposes:
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Yes
No
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