Music Therapy Intake Form - Ages 0-22 Header Image

Music Therapy Intake Form for Ages 0-22

Welcome to the Music Therapy program at Levine Music!

It is our goal at Levine Music to provide you with high quality music therapy services, support, and communication regarding the needs of your child. We provide an environment that is well-informed, supportive, enjoyable, and successful.We want you to be an integral and active participant in therapy and learn how to provide an environment that will support your therapeutic progress. We also want you to be involved in establishing goals, treatment planning, home exercises, and discharge planning.Our intention is to move towards a level of independence within everyone’s abilities.

Below is our Music Therapy Intake Form for Ages 0-22. The form is completely confidential and any information gathered will be used to plan a comprehensive assessment session for you/your loved one. The form will be sent to us electronically.Once we receive the form, we will contact you to schedule an assessment date and time. Please note that this form MUST be received prior to your child’s initial assessment.

We look forward to working with you!

The Music Therapy Department at Levine Music
2801 Upton Street NW
Washington, DC 20008
(202) 686-8000 ext. 1103

CONTACT INFORMATION

Student's Name*
Date of Birth*
Parent/Guardian Name*
Address*
Secondary Contact*

ENROLLMENT INFORMATION

What type of music therapy session do you/your child prefer?*
Which Levine Campus do you prefer?*
Check as many as apply

Please indicate your preferred days and times for sessions below:

How did you hear about Levine School of Music's Music Therapy Department?*

GENERAL & MUSICAL INFORMATION

Does the child have siblings?*
Is your child adopted?*
Has the child had any previous music therapy services?*
Has the child taken music lessons before?*
Does the child display musical skills or abilities?*
Are there musicians in the child's immediate family?*
Please specify.

DIAGNOSTIC, MEDICAL & SAFETY INFORMATION

Does the child have specific diagnoses or medical issues?*
Is the child currently taking any medications?*
Does the child have allergies or diet restrictions?*
Does the child experience seizures?*
Is the child able to use the restroom independently?*
Are there any precautions that should be taken in working with the child?*
Does the child display aggression towards self or others?*
Does the child engage in destruction of property, verbal outbursts, or disruptions?*
Does the child have any additional medical or safety concerns?*

ACADEMIC & COGNITIVE INFORMATION

Does the child have an aide in school?*
Is the child mainstreamed during the school day?*
Does the child work in a vocational setting?*
Does the child have an IEP or other formal treatment plan?*
Is the child able to read?*
Is the child able to write?*
Is the child able to use the computer or similar technology?*
Is the child able to identify colors, numbers, and letters?*
Does the child benefit from a visual or written schedule?*
Is the child able to follow directions independently?*
Does the child have difficulty maintaining attention to directions and/or tasks?*

OTHER THERAPIES & ACTIVITIES

Does the child receive any therapies (OT, PT, SLP, Counseling) at school?*
Does the child participate in any private therapies outside of school?*
Is the child enrolled in any extracurricular activities? *

MOTOR SKILLS

Does the child have any gross motor difficulties?*
Is the child fully ambulatory?*
Does the child have any fine motor difficulties?*
Is the child able to perform fine motor tasks with both hands? *
Does the child frequently drop items or have difficulty holding items?*

SENSORY

Does the child have hearing and/or vision deficits?*
Does the child have a history of ear infections?*
Does the child have sensory processing issues? *
Is the child over-stimulated by lights, crowds, or sounds? *
Does the child engage in any repetitive behaviors? *

COMMUNICATION

Does the child display any speech or language difficulties *
Does the child communicate verbally? *
Does the child use augmentative or alternative communication? *
Do others easily understand the child’s speech?
Does the child ask/answer questions? *
Does the child have idiosyncratic speech (repeated words, non-functional speech)? *

EMOTIONAL

Does the child appropriately display emotions? *
Does the child possess any abnormal fears or anxiety? *
Does the child tantrum or anger easily? *
Has the child suffered any emotional trauma or recent life changes? *

SOCIAL

Does the child have any social difficulties? *
Are there particular settings in which your child experiences more difficulties? *
Does the child engage in conversation with others? *
Does the child participate appropriately in group activities? *
Does the child participate appropriately in one to one settings? *
Does the child have any special skills or interests? *

ADDITIONAL INFORMATION

Have you been approved for funding through a third party source to cover your music therapy services?*
Are you interested in submitting for reimbursement through your insurance provider?*
*Please note that insurance reimbursement is the family’s responsibility and is not guaranteed. Tuition is due to Levine at the time of service regardless of reimbursement.*
Date*

Please Note: Once the completed Music Therapy Intake Form is completed and submitted to Levine Music’s Music Therapy Department, the Director of Music Therapy will contact you to schedule a 45-minute music therapy assessment with your child.

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