Rejoice Music Therapy

New Client Intake form

Name of Client

Name of adult filling out this form & relationship to Client.

Client gender

Registering for:

Multi-line address

Country/Region

Address

City

Zip / Postal code

Client date of birth

Month

Day

Year

Phone

What is your preferred way of being contacted?

How did you hear about Rejoice Music Therapy?

Do any of the following describe the client? (This question is to ensure client needs are met to the best of our ability.)

Uses a wheelchair

Uses a walker, cane, or other assistive ambulation device

Hearing impaired, not corrected by hearing aids or cochlear implant

Visually impaired, not corrected by eyeglasses or contacts

Please list any client allergies or type "none".

Please tell us about the client's previous musical experience, although none is required to participate and/or benefit.

Please tell us about the client's preferred music or favorite songs.

Please list any other therapies or community programs in which the client participates.

Does the client have any diagnoses of which we should be aware?

Are there specific reasons or general goals that have influenced you to choose music therapy? (behavior, cognitive, communication, sensory needs, anxiety, depression, coping, wellness/self-care, spiritual support, self-expression, or other areas)

Is there anything else you would like to share about the client?