Family Music MT Intake Form

This semester during the Family Music Classes, I’ll be supervising music therapy students from Texas Woman’s University as they learn skills necessary to become a Board-Certified Music Therapist. They’ll be required to document on group goals and objectives as well as occasionally lead music activities under my leadership. Your answers here will help them better learn how to be music therapists as well as help me better plan our classes.
Documentation remains private, between Coyote Music Studio and you. TWU students will receive a class form from me with condensed info - without your personal, identifying information. Your full information will not be given to TWU or the city of Denton, where classes are held. - Tonya S. Blum, MA, MT-BC

You can fill out the Music Therapy Intake Form below and it will go directly to your music therapist, Tonya Blum.
All information remains private. It will not be shared outside of your therapeutic relationship and will only be used by Coyote Music Studio to improve your music therapy services while teaching music therapy students from TWU.

If you prefer to download the form and email it or bring it with you, scroll to the bottom for a PDF version.

Information on how and why this form is being used

Music Therapy is the use of music interventions designed for individuals/groups to accomplish their personal, non-musical goals. It’s is an ongoing, therapeutic service in which a Board-Certified Music Therapist and a client (or group) develop a relationship through music to accomplish non-musical goals, such as improve social/emotional states, increase communication, develop/improve fine and gross motor skills, improve academics, improve quality of life, and others.

Music Therapy Workshop Intake Form

* Indicates required field

Student's Name *

First

Last

Date of Birth *

Parent/Guardian's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Student/Client Diagnosis(es), N/A if none *

What's something important I should know about the student? *

What skill areas would you'd like to address in music class or Music Therapy? *

Others, please list *

List at least 1 personal goal for each area checked above. *

What are some ways the student reposnds to music at home or in the community? *

What type of music (or specific songs) does the student sing, dance, or respond to most at home? *

Does the student receive other therapies? If so, please list important objectives the client is already working on. These can be reinforced in music therapy. *

I understand that this information will only be used by my Board-Certified Music Therapist, Tonya S. Blum, MA, MT-BC, in order to improve my music therapy services and will not be shared outside of my therapeutic relationship. I assure that all information in this form is accurate and truthful. My name and today's date in the box below serves as my signature for this form.

Signature and Date *

I agree to receiving marketing and promotional materials *

Submit

You can also download the form and return it to [email protected] or bring it to class.

family_music_mt_intake_form1.pdf
File Size:	238 kb
File Type:	pdf

Download File

Family Music Class, Music Therapy Intake Form

Information on how and why this form is being used

Music Therapy Workshop Intake Form

You can also download the form and return it to [email protected] or bring it to class.