Client Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Parent/s or Guardian/s Names (enter N/A if non applicable)
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Occupations of Guardians/ Occupation of Adult Client
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Siblings & Ages
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Home Phone
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(###)
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Mobile Phone
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(###)
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Email
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Address (full address, including city and postal code)
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Billing Info (PLEASE SELECT ONE): 1) Private Pay 2) AFU (Autism Funding Unit) children age 6-19 are eligible, 3) Variety Children's Charity, 4) Self Design Learning Foundation, 5) E-bus Academy, 6) Kleos Open Learning, 7) e-streams Christian Homelearning, 8) Squiala Nation, 9) Squamish Nation, 10) Music Heals, TLA Online (Traditional Learning Academy), 11) CKNW Kid's Fund 12) other
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Client Assessment/Diagnosis
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Communication- how do you/ how does the client communicate? (ie. verbal, non verbal, sign language, communication device, gesturing)
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Medical Concerns/Considerations
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Treatment Team Case Manager
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Speech and Language Pathologist
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Occupational Therapist
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Behavioral Interventionists/ Agency
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Other Therapy/ Therapists
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School Name (if applicable)
Programs Currently Enrolled in
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Client Goals & Objectives - Treatment Plan
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Client Strengths
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Client Challenges
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Preferred Activities
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Music Preferences (genres, instruments, favorite songs/singers/groups)
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Please add as much detail here as possible!
Desired Outcomes- Music Therapy
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Additional Comments
ET Music Therapy Service Agreement
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1. Session cancellation notice must be received 24 hours before scheduled session day and time. Cancellation notices given less than 24 hours of the scheduled session will result in full session charge, on the next monthly invoice. All cancellation notices should be sent to your therapist directly via text/email.
2. No more than one session cancellation per month is permitted, even with extensive notice. Cancellation of more than one session per month is allowed in only extreme circumstances, as discussed, prior to occurance, with the business manager, and agreed upon by ET Music Therapy. More than one session cancellation per month will result in full charge of second, third, and forth cancelled session/s etc.
* If client receives sessions twice a week, then a commitment of six sessions per month is required (two cancellations per month is permitted).
* If client receives sessions twice per month, then a commitment of 3 sessions within 2 months is required (one cancellation per every 2 months is permitted).
* Summer vacations up to 2 weeks per year are permitted at no charge.
* Spring break 2 weeks no sessions are permitted at no charge.
* STAT holidays are optional. Please discuss with your therapist.
* Christmas holidays up to 2 weeks are permitted at no charge. Please note, some of our therapists are open to working throughout the holidays so please discuss with your therapist.
*for any month in which a 2 week holiday is taken by the family, no extra week of cancellation is permitted that month (ie. 2 weeks vacation in July, one week sick, even with 24 hours notice, will result in a charge of 2 sessions in July).
3. Four Week Trial Period- Building a strong rapport and trust between therapist and client can often take time. The staff of ET Music Therapy are dedicated to the relationship and commitment to service with a client, dedicated to completing a thorough assessment, and dedicated to creating a personalized therapy plan for each individual client. After 4 trial sessions, you can decide if this is the right fit for your family- at which time a commitment of 6 months of service with a client at ET Music is required from each participant/family. This intake form is NOT required to be signed until after the 4 week trial period is complete.
4. Discontinuation of Services: 2 weeks notice is required when reqeusting discontinuation of your dedicated weekly/biweekly time slot. Thank you for your consideration. NOTE: Notification of discontinuation must be sent to Esther Thane, Executive Director etethane@gmail.com, AND/OR Vince Thane, Business manager ecnivthane@gmail.com
Ethnicity
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Language Spoken at Home
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