New Client Intake Form

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Puget Sound Music Therapy
Helping you to reach full potential through music
253.448.1400
 
 
New Client Intake Form
Name: _____________________
Age: _______________
DOB: _____________________
Date Completed: ____________________
Referring Person: ______________________________________________________________
Address: _____________________________________________________________________
____________________________________________________________________________
Phone 1
: ________________________________________________________
(office/home/cell)
Phone 2
: ________________________________________________________
(office/home/cell)
Fax: ________________________________Email: ___________________________________
Current Diagnosis and given by whom: ____________________________________________
Medications?
____________________________________________________________________________
Allergies/sensitivities:__________________________________________________________
Any precautions therapists should take?
____________________________________________________________________________
Other therapies participated in:
____________________________________________________________________________
Music Preferences:
____________________________________________________________________________
What benefit do you anticipate?
____________________________________________________________________________
Motor Skills
Any gross Motor difficulties? (full use of limbs, ambulatory, etc): yes/no
If yes, describe:_________________________________________________________
Fine motor difficulties? (grasping, holding objects) yes/no

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