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Client Intake Form
Private Clients - Kids/Adolescents
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* Indicates required question
Email
*
Your email
Phone Number
Your answer
Date
*
MM
/
DD
/
YYYY
Name (Parent/Guardian)
*
Your answer
General Information
Name (Client)
*
Your answer
Age
*
Your answer
Level of Education
*
Your answer
Name of School
*
Your answer
English as first language
*
Choose
Yes
No
Medical Information
Diagnosis
*
Your answer
Number of years
*
Your answer
Involvement in other forms of therapy
*
Choose
Yes
No
If yes, list therapies:
Your answer
Medications
*
Choose
Yes
No
If yes, list medications and reasons:
Your answer
Behavioural Information
(E.g., Social skills, general attitudes/moods, etc)
*
Your answer
Musical Information
Level of Musical Background (if applicable)
Your answer
Musical Preferences (e.g., genres, singers, songs)
*
Your answer
Goals and Inquiries
What are you hoping to get out of these sessions?
*
Your answer
Do you have any questions or concerns?
Your answer
Other Comments
Your answer
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