Music Therapy Questionnaire
Client's Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Client’s Preferred Pronouns (Ex: She/He/They)
Client’s Phone
Client’s Email
example@example.com
Client’s Address
Client's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Name
Primary Contact Relationship to Client
Phone
Email
example@example.com
Client’s Diagnosis
Diet Restrictions
Allergies/Medical Precautions
Does the client have a history of seizures?
Yes
No
EpiPen:
Yes
No
Hearing
Vision
Primary Spoken Language
Do you need Interpreting Services?
Yes
No
Other Current Providers
Preferred Availability for Scheduling (Check All Preferences):
Telehealth (Online Sessions)
Session in Client's Home
Session at Twin Cities Music Therapy Services' Clinic (South Minneapolis)
Funding Source for Music Therapy (Check One)
Out-of-Pocket Private Pay
Fiscal Support Grant (FSG)
Consumer Support Grant (CSG)
HCBS Waiver
Other:
First Choice: Day(s) and Time(s)
Second Choice: Day(s) and Time(s)
I could also make these day(s) time(s) work
What is your preferred session length?
30 Minutes
45 Minutes
60 Minutes
Prefer to wait and see how it goes.
Which HCBS Waiver do you have? (Check one)
DD
CAC
BI
CADI
Which service option do you have for your Wavier? (check box)
Consumer Directed Community Supports (CDCS)
Independent Living Skills Therapies (ILS Therapies)
What is the annual renewal date for your waiver?
/
Month
/
Day
Year
Date
What are the skills-based reasons for referral to music therapy services?
CDCS Waivers and CSG Only:
Fiscal Management Service (FMS)
CDCS Waivers, CSG, and Out-of-Pocket Only:
Invoicing Preferences:
email invoices to me
mail invoices to me (USPS)
email invoices to FMS directly
Contact Name for Invoices
Contact Information for Invoices
Email Address and/or Postal Mailing Address
All HCBS Waivers:
Name of Case Manager
Case Manager’s Phone
Case Manager’s Email
example@example.com
Goals and Priorities
Which areas would you like to address in music therapy?
What activities does the client enjoy?
What do you consider to be this client’s greatest strengths?
Does this client have any favorite songs or styles of music?
Please tell us about any cultural considerations you would like us to be aware of.
Please tell us about any behavioral needs this client may have. What strategies you have found helpful to support regulation structure, visual schedules, sensory input, etc?
Please tell us about how this client communicates verbal, sign language, non- verbal, assistive technology, etc?
Is there anything else you would like us to know about this client?
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