Client Name (first name, last initial):

Checklist Completed By

Relationship to client

Date (DD/MM/YY)

Contact information including phone number AND email:

Please describe the individual or group being referred to music therapy below in each relevant section. Please be as detailed as possible and note that the owner (Alicia Hubbard) will be in touch to get any other information needed and to discuss setting up an assessment of the individual or group to see if that can be accommodated.

Primary Diagnosis

Other Medical

Personal History Summary (any information about the client or group)

Social Skills and Behavioral

Sensory Systems (including reflexes) and Memory (Long and Short Term)

Basic Concepts such as weather, colors, shapes, time, animals, alphabet, money concepts, calendar, numbers, and reading ability

Range of Motion

Gross Motor (large movements)

Fine Motor (small movements)

Difficulties with Activities of Daily Living as well as any fears

Client strengths

Client difficulties

Your insight and hopes for therapy goals

Musical Preferences/ Past Music Experience/ Favorite Songs: