Rhythmic Integrations Intake Form

Please complete this client intake form at least 7 days prior to your first session. I look forward to meeting you.

Contact Name

Contact number

Name of participant/child

Date of birth of participant/child

Address of participant/child

Please list the participant's/child's strengths

Please list the participant's/child's diagnosis/es

Please list any therapy professionals or other programs currently being accessed

Please email any relevant therapy, medical or educational reports through to [email protected] 7 days prior to your first session. This information will provide a bigger picture of you/your child's needs and also ensure best use of session time.

What are you hoping to get out of Neurologic Music Therapy (NMT) and/or Spelling to Communicate (S2C) sessions for yourself/your child?

Please list a couple of the participant's/child's likes and dislikes

Please include both musical if any (particular instruments or songs/artists?) and nonmusical (eg. trains, dinosaurs, painting etc)

Is there anything in particular that regulates the participant/child down when anxious/upset/frustrated etc

Please note for those with high anxiety: A picture of myself and the clinic rooms can be emailed prior to first session upon request. Being able to see a new place and person in advance can sometimes ease just a little bit of the anxiety involved in the change of routine in starting new therapy programs and/or meeting new people.

Is the participant/child NDIS funded?

If Yes - please email a copy of the NDIS goals to [email protected] 7 days prior to first session. Please note Rhythmic Integrations is not registered with the NDIS, therefore funds from self or plan managed plans only can be used. Agency managed plans require registered providers.

Yes - self managed Yes - agency managed Yes - plan managed No

As part of NMT/S2C sessions we tend to provide some 'homework' - ie. tasks or recommendations of things that can be done outside the session to improve non-musical goals. Are you in a position to receive new information and endeavour to carry out tasks provided?

Yes No

Is there any other information you would like to share?

Please provide at least 2 preferred days and times for sessions.

Early Childhood Professionals

Rhythm and Movement for Self Regulation

MusicTalk

RAMSR

Original (3-8yrs)

Toddler (18 Months – 3.5 Years)

In Person Training

Families

Spelling to Communicate

Neurologic Music Therapy

Resources

Courses

Rhythmic Integrations Intake Form

Quick Links

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