Voices Together at Ragsdale YMCA Intake Form Please let us know a little bit about the person who might benefit from Voices Together Music Therapy. We look forward to meeting you and your child at our upcoming session. Question Title * 1. Client Name: Question Title * 2. Client Age and Date of Birth: Question Title * 3. Client Gender: Male Female Question Title * 4. Parent or Guardian Contact Information: Name: * Relationship to Client: * Street Address City/State/Zip Code Email Address * Phone Number * Question Title * 5. Emergency Contact Information: Name: Relationship to Client: Phone Number: Email: Question Title * 6. Client diagnosis: Question Title * 7. Is the client verbal or non-verbal? Verbal Non-verbal Other (please specify) Question Title * 8. Client communication goals: If Client is non verbal - Initiate intentional communication If Client is verbal - Initiate language Maintain language in a conversation Listen when someone speaks Other (please specify) Question Title * 9. Client social goals: Participate in a group setting. Express his/her feelings in a group setting. Interacts with peers in a group setting. Self-regulate behavior in a group setting. Other (please specify) Question Title * 10. Does the client need extra support in a group setting? (please specify) Question Title * 11. Do you have any other comments, questions, or concerns? Done