CLIENT INTAKE - Developing Melodies Music Therapy Center

Basic Information
Are you filling this form out for yourself or someone else?*
Relationship to the Client:*
With whom may we share the information from this form?*
Client's Name:*
First Last
Client Date of Birth*
MM slash DD slash YYYY
Client Gender:
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone Number:*
Other Phone Number:
Would you like to communicate through text message?*
This communication may include contact for reminders, cancellations, weather updates or changes. It will not include sensitive information or reports.
- Primary Phone Number
- Other Phone Number
- No Texting Please
Email:
Best Way to Contact:
- Phone
- Email
- Text
- Other
Primary method(s) of communication (client):*
- Verbal
- Gesture/Sign Language
- AAC Device (pictures, iPad, button system, etc.)
- Other
Primary Language Spoken in the Home:*
Other Languages Spoken:
How did you hear about Developing Melodies?
What is your availability for an evaluation session?*
To assist us in scheduling an evaluation, please indicate which days you are generally available (M-F) and whether you have morning (9am-12pm), afternoon (12pm-4pm), or evening (4pm-7pm) availability. Evaluation sessions last ~30 minutes.

Medical Information
Diagnosis (if known):*
Primary Physician (PCP):*
Name
Physician Phone:*
Other doctors and specialists who are involved in the client's care:
Please list names, specialties and phone numbers.
Other therapies received (physical therapy, occupational therapy, speech therapy, etc.):
Please list names, specialties and phone numbers.
Did the birth and delivery of your loved one contribute to their current condition? If so, how?*
Did your loved one suffer an accident that has contributed to their condition? If so, how?*
Any other medical issues?*
Any physical assistance required or assistive equipment used? If so, please describe.*
Current medications:
Please list.
Any known allergies? Please describe:*
Any diet restrictions? Please describe.*

Please indicate if you are filling this form out for an adult or child.
- Child
- Adult

Social/Emotional History: Child
Please disregard this page if the client is over 18 years of age
Parent/Guardian 1 Name and Occupation:
First Last Occupation
Parent/Guardian 2 Name and Occupation:
First Last Occupation
Parent/Guardian Marital Status:
Is your child adopted?
- Yes
- No
Sibling(s) of the client (names, ages):
Is the child currently enrolled in school/daycare? If "yes", where and what days attended?
Does the child have a current Individualized Education Plan (IEP) or Individual Service Plan (ISP)?
- Yes
- No
What are your child's favorite toys/activities?
What are your child's favorite music styles or songs?
What typically calms or soothes your child?
Is your child currently enrolled in any community activities (music class, playgroups, sports, Penguin Project, Seedling Theater, etc)?
Are there any emotional/behavioral issues that we should be aware of? (Seizures, self-injurious behaviors, biting, etc.) If yes, please explain.
Has there been any recent trauma or change in life circumstances? If yes, please explain.
Anything else you would like to tell us about your family?

Social/Emotional History: Adult
Please disregard this page if the client is under 18 years of age
Marital Status:
Family member(s) name(s):
Spouse, Children, etc.
Client current employment status:
Does the client have a current Individualized Education Plan (IEP) or Individualized Service Plan (ISP)?
- Yes
- No
What are some favorite activities?
What are some favorite songs or artists?
What are some things that you/the client find soothing or calming?
Are you/is the client currently enrolled in any community activities (sports, music class, Miracle League, Penguin Project, Special Olympics, etc.)?
Are there any emotional/behavioral issues that we should be aware of? (seizures, self-injurious behaviors, biting, etc.) If yes, please explain.
Has there been any recent trauma or change in life circumstances? If Yes, please explain.
Anything else you would like to tell us about your loved one or family?

Basic Information