Music Therapy Intake Form
Neurologic Music Therapy
Client Name
*
First Name
Last Name
Client Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If Applicable, Please Provide Name of Primary Caregiver
First Name
Last Name
Relationship to Client
Primary Caregiver Phone Number
Format: (000) 000-0000.
Primary Caregiver Email
example@example.com
Primary Caregiver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
May we contact the above caregiver and share information regarding your care and treatment progress including session documentation?
Yes
No
Is the client's healthcare power of attorney activated?
Yes
No
If yes, please provide information about healthcare power of attorney:Â Â Â Â Â Â
Name:
        Â
Phone Number:
           Â
Relationship to Client:
  Â
Where we can contact you regarding appointments?
*
Phone Number
Format: (000) 000-0000.
Who does the above phone number belong to?
*
First Name
Last Name
Relationship to Client
May the above phone number be used for purposes of texting appointment reminders?
Yes
No
Email where we can communicate with you regarding appointments, where we can send documents to be signed, or send assessments/progress notes:
*
example@example.com
Who does the above email belong to?
*
First Name
Last Name
Relationship to Client
What is the preferred form of communication?
*
Phone
Text
Email
Financially Responsible Party
*
First Name
Last Name
Relationship to Client
Where We Can Send Invoices?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address Where We Can Send Invoices
*
example@example.com
Primary Insurance Company
Primary Insurance Group Number
Primary Insurance Policy Number
Secondary Insurance Company
Secondary Insurance Group Number
Secondary Insurance Policy Number
Diagnosis or reason for seeking neurologic music therapy services?
*
What goals are you hoping to achieve throughout your neurologic music therapy sessions?
*
Are there any medical needs that may arise during your music therapy sessions?
Yes
No
Please describe
*
Emergency Contact
*
First Name
Last Name
Relationship to Client
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Any questions or concerns?
Submit
Should be Empty: