New Client Information Form

Name of Client

Date of Birth

Name of organization, school, program or workplace:

Diagnosis:

If there are any special requirements due to the client's conditions, please specify here:

What aims do you hope to achieve from music therapy/art therapy?

What is the client's level of language development (both receptive and expressive abilities)?

What is the client's social skill level (ability to relate to others, understand feelings)?

What is the client's level of general comprehension?

Does the client have any sensory impairments/difficulties? (vision, hearing, touch etc.)

Does the client have any physical limitations (such as difficulty with unassisted walking, balance, and/or wheelchair dependent)?

Family structure and living environment:

Medication (if any):

For music therapy, does the client have any preference to certain musical styles and/or favorite songs? For art therapy, does the client have any preference to certain art styles, e.g. drawing, painting, collage, sculpture etc. If so, please list.

Does the client exhibit any behavioral problem? If so, please specify.

Has the client had any previous/current music therapy and/or art therapy experience? Or any music/art related workshops?

Please indicate available days and time for weekly sessions. If unavailable, please leave blank.

Monday

Wednesday

Friday

Tuesday

Thursday

Saturday

How did you hear about our service?

If the client attends other therapies such as behavioral therapy, psychologist counseling, speech therapy, and occupational therapy, could you please provide the therapist names and contact details? (We will ask your permission prior if we will make a contact with any of them.

This client will be accessing this service through:

NDIS

Private

Other fundings

NDIS Funding type (mandatory for NDIS clients):

Self-Managed Funding

Plan-Managed Funding

NDIA-Managed Funding

NDIS Number (mandatory for NDIS clients):

NDIS plan starting date:

NDIS plan ending date:

This form was completed by:

Association to the client:

Your Signature

Date of form completion

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