CLIENT INTAKE - Developing Melodies Pediatric Therapy and Music Learning

Patient Intake Form

Looking to learn more about music therapy services for your child? Please complete the intake form below to the best of your ability. Once you submit this form, our clinical director will contact you when an appointment becomes available. If you are seeking contract services or have other questions, please contact our director Meryl Brown at Meryl@DevelopingMelodies.com.

Personal Information

Patient Name(Required)

First Last

Patient Pronouns

Patient Birthdate(Required)

Patient Age(Required)

Please enter a number from 0 to 18.

Patient Needs and Diagnosis(Required)

Parent/Guardian Name(Required)

First Last

Relationship to Patient(Required)

Patient Sibling Name(s)(Required)

If no siblings, please respond with N/A

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Emergency Information

Emergency Contact Name(Required)

First Last

Emergency Contact Number(Required)

Relationship to Patient(Required)

Patient Information

Patient's Current School or Early Learning Program(Required)

Grade Level(Required)

Does the Patient have an IEP, IFSP, or 504 Plan?(Required)

Please tell us about the patient's medical needs.(Required)

ie. current medications, precautions, allergies, sensitivities, etc. that we should be aware of for therapy.

Please tell us about the patient's communication abilities.(Required)

Speaking? Non-Speaking? AAC? Sign Language? Expressive Communication? Receptive Communication? Can they answer WH questions? Can they answer Yes/No questions? Open Ended? Can they ask questions?

Please tell us about the patient's social abilities.(Required)

Can they socialize with peers or adults independently or with support? Exhibit other's awareness? self-awareness?

Please tell us about the patient's cognitive abilities.(Required)

Can they identify colors, letters, shapes, animals, numbers? Pre-literacy? Reading?

Please tell us about the patient's emotional needs.(Required)

Can they identify their own emotions? Can they express them speaking? non-speaking? Can they identify others' emotions? How to they handle change?

Please tell us about the patient's attention abilities.(Required)

Can the patient wait their turn? Can they share with others? Do they utilize flexible seating? What kind? Do they benefit from sensory props or fidgets? What kind(s)?

Please tell us about the patient's behavioral needs.(Required)

Does the patient have any activators? Does the patient have any unsafe behaviors we should be aware of? Does the patient elope? Is the patient prone to self-injury? Other's injury? Is the patient continent?

Please tell us about the patient's fine motor abilities.(Required)

Hand dominance? Hand eye coordination? Hand grasp? Pincer grasp? Any specific tone needs?

Please tell us about the patient's gross motor abilities.(Required)

Ambulatory? Independent upper body movements? Bilateral movements (left and right side together)? Can they cross midline? Independent lower body movements? Any motor planning needs we should be aware of?

Please tell us about the patient's musical interests and abilities.(Required)

ie. favorite songs, favorite types of music, favorite instruments, bands, singers, dances, etc. *musical ability is NOT a requirement for music therapy.

Does the patient have any adverse responses to certain sounds, musical instruments or songs we should be aware of?(Required)

Please describe.

Tell us about some things that are motivating for the patient.(Required)

ie. positive praise, stickers, smiles, high fives, snack rewards, TV shows, games, movies, etc.

Does the patient participate in other therapies or adaptive programs?(Required)

Please describe.

Trauma Informed Disclosure

If there is a traumatic event or situation the patient has experienced that you would like to disclose to the therapist, please detail it here or in a way that feels most comfortable for you and the patient. Otherwise, leave this area blank.

Developing Melodies Policies and Procedures

Who We Are(Required)

*Developing Melodies seeks to provide outstanding music therapy services, support and communication to prospective and current patients and their families. We strive to curate a safe and nurturing environment that is accessible, warm, positive and well informed. At Developing Melodies we seek to meet the needs of all people of all abilities in an inclusive and collaborative way with the intention of cultivating self-directed outcomes and growth.

I have read the Who We Are statement.

Therapist Credentials(Required)

All Developing Melodies music therapists hold the LPMT (licensed practicing music therapist) license through the State of Illinois Department of Financial and Professional Regulation, Division of Professional Regulation and the MT-BC credential through the Certification Board for Music Therapists. Additionally, All Developing Melodies music therapists carry professional liability insurance. A copy of your therapists license, credentials or insurance certificate may be requested from Meryl@DevelopingMelodies.com

I have read the DM credentials as outlined above.

Non-Discrimination Policy(Required)

All therapists and staff at Developing Melodies seek to meet the needs of all people of all abilities without discrimination of any kind including but not limited to: sexual orientation, race, color, national origin, gender, sex, age, religion or disability.

I have read the non-discrimination policy.

Privacy is of the utmost importance in therapy. In accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules, yours and the patient's personal and medical information will remain strictly confidential unless authorized with your written consent. If you would like a copy of the full HIPAA policy of Developing Melodies, please contact Meryl@DevelopingMelodies.com

I have read the privacy policy and statement.

Payment and Reimbursement(Required)

At this time, all music therapy services are to be paid out of pocket, private pay. If interested in seeking reimbursement for therapy services with your insurance company, please talk with our clinical director, Meryl Brown (meryl@developingmelodies.com), who can provide your with the paperwork necessary for your inquiry. All service reimbursement is the responsibility of the patient family. And all payments must be paid in full before seeking reimbursement. Developing Melodies does not seek reimbursement for you.

I have read and understand the reimbursement policy and statement.

Attendance Policy(Required)

Your consistent and prompt attendance is expected on your designated day and time of therapy unless previously arranged with your therapist. Please notify your therapist at least 24 hours prior to an absence. If you have an early AM session we kindly ask that you call or text your therapist the night before (or text as early as possible that morning) to give them notice of an absence. No shows with no call ahead will incur a full session fee charge. In the case that your therapist is absent for any reason, they will communicate their absence to you as soon as possible and you will not be charged for their absence. Make up sessions are scheduled on a case by case basis.

I have read the attendance policy outlined above.

Payment Procedure and Policy(Required)

Payment is due upon receipt of monthly invoice unless previously arranged, in writing, with Developing Melodies. Invoices are sent electronically. Acceptable forms of payment include cash, check (Made out to "Developing Melodies") or electronically through the invoice system. Payments may be mailed to "Developing Melodies, 705 E Lincoln St. Suite 209, Normal IL 61761". Payments are considered late if not sent within 14 days of invoice date. Late payments will incur a $20 fee. If payments are not received by the next invoice, a patient may be removed from the therapist's schedule until all payments are received, thus possibly forfeiting their time slot. Returned checks for any reason will incur an immediate $25 fee and any associated bank fees in addition to the total amount due.

I have read the payment procedure and policy.

Good Faith Estimate(Required)

Per the No Surprises Act which went into effect on January 1, 2022, you are entitled to receive a “Good Faith Estimate” of the cost for music therapy services at Developing Melodies. While it is not possible to know, in advance, how many sessions may be necessary or appropriate for any given client, we will provide an estimate of the cost of services. Your total cost of services will depend upon the number of months you attend music therapy sessions, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from Developing Melodies, nor does it include any services that may be recommended during treatment to you that are not identified in the estimate. The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of music therapy sessions. The number of sessions that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

I understand that I will receive a "Good Faith Estimate" of service costs before I consent to services.

Weather Policy(Required)

Unsafe weather is unfortunately inevitable in Central Illinois. In the case that sessions are canceled on your session day due to unsafe weather conditions or an emergency, your therapist will contact you as soon as possible to cancel your session. You will not be charged for canceled sessions due to unsafe weather conditions or emergencies. Make up sessions for unsafe weather cancellations will be scheduled on a case by case basis.

I have read the weather policy outlined above.

Liability Policy(Required)

While Developing Melodies holds a liability policy, we require all families and students to be accountable for their actions. Developing Melodies holds individuals and families accountable for engaging in safe and respectful behaviors while in the studio and will charge clients for any damages done to Developing Melodies property.

I have read the liability statement.

Termination Policy(Required)

Termination will take place when all goals in therapy are met. However, If you feel that music therapy is not benefiting your family member, you may request discontinuation of services. Requests for termination must be made in writing. In the spirit of closure and because therapeutic relationships have been formed, we request at least 2 weeks advanced notice for termination. Likewise, Developing Melodies therapists follow necessary protocols to combat regression or lack of progress. However, in the case that progress is still not made, your therapist reserves the right to discontinue services as deemed therapeutically appropriate or when ethically necessary.

I have read the termination policy.

Patient Information

What do you want the patient to get out of music therapy?(Required)

While we strive to do our best with scheduling, we may not always have space available at the times you request. Please share your availability with us so that we may try to schedule you accordingly.(Required)

Currently, we are building our schedule for summer (2025) sessions. Typically, our services are offered on Tuesdays, Wednesdays and Thursdays 9:00am-2:00pm.

How did you hear about Developing Melodies?(Required)

Friend/Family Member

School/Therapy Provider

Social Media

Internet Search (Google, Yahoo, etc.)

Other