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.

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* 1. Client Name:

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* 2. Client Age and Date of Birth:

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* 3. Client Gender:

Male

Female

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* 4. Parent or Guardian Contact Information:

Name: *

Relationship to Client: *

Street Address

City/State/Zip Code

Email Address *

Phone Number *

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* 5. Emergency Contact Information:

Name:

Relationship to Client:

Phone Number:

Email:

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* 6. Client diagnosis:

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* 7. Is the client verbal or non-verbal?

Verbal

Non-verbal

Other (please specify)

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* 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)

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* 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)

Voices Together at Ragsdale YMCA Intake Form

Question Title

* 1. Client Name:

Question Title

* 2. Client Age and Date of Birth:

Question Title

* 3. Client Gender:

Question Title

* 4. Parent or Guardian Contact Information:

Question Title

* 5. Emergency Contact Information:

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* 6. Client diagnosis:

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* 7. Is the client verbal or non-verbal?

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* 8. Client communication goals:

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* 9. Client social goals:

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* 10. Does the client need extra support in a group setting? (please specify)

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* 11. Do you have any other comments, questions, or concerns?