Music Therapy Termination Form
Please complete this form to document the conclusion of music therapy services. Your feedback and information help us ensure quality care and proper closure.
Client Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Therapist Name
*
First Name
Last Name
Date of Final Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Client achieved therapy goals
Client discontinued voluntarily
Therapist recommended termination
Administrative/Logistical reasons
Other
Summary of Progress and Outcomes
*
Client's Feedback on Music Therapy Experience
Therapist's Recommendations (if any)
Was the client satisfied with the overall experience?
Yes
No
Partially
Please rate your overall experience with music therapy
1
2
3
4
5
Signature (Client or Guardian)
*
Submit Termination Form
Submit Termination Form
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