Music Therapy Intake formplease complete this form prior to your first music therapy session Parent to receive invoice and reminders First Name Last Name Secondary Parent/Caregiver name if applicable First Name Last Name Client Name * First Name Last Name Phone (###) ### #### Email (to receive invoice and reminders) Preferred contact method Text Email Phone Call Client's Birthday MM DD YYYY Diagnosis (if applicable) Address (location for sessions) Address 1 Address 2 City State/Province Zip/Postal Code Country FES ID number (if using FES scholarship) leave blank if not Other Therapies Received Speech Language Pathology Physical Therapy Occupational Therapy Mental Health Counseling Art Therapy Behavioral Therapy/ACBA/RBT Other Clients goals in other therapies (if known) Contact info of therapists listed above (optional) Reason for seeking music therapy Thank you!
