Client Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
DOB
*
MM
DD
YYYY
Pronouns
Best Contact Method
*
By checking one of the boxes for Best Contact Method, I agree to receiving correspondence from Maestro Music Therapy
Financially Responsible Party
If different, please complete section below
Financially Responsible Party
First Name
Last Name
Relationship to client
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
Emergency Contact
Please provide at least one
First Name
Last Name
Phone
(###)
###
####
Relationship to client
Emergency Contact #2
First Name
Last Name
Phone
(###)
###
####
Relationship to client
Referral Source
Relevant Medical Issues/History
Relevant Family History
Please describe the client’s current abilities, needs, and support areas across the following domains: Social/Emotional, Motor, Communication, Cognitive, and Sensory.
Prior Music Therapy Experience, if any
Musical Preferences
Reasons for coming to music therapy/Goals for treatment
Other services currently providing treatment
Any additional information relevant to Music Therapy treatment
Acknowledgement:
I, the undersigned, certify that the information above is accurate to the best of my knowledge.
First Name
Last Name
Date
MM
DD
YYYY
