Music Therapy Sign-up Form

Please click Here if you are looking for non NDIS funded music lessons.

Confidentiality Statement

Client information will not be shared in any way without the client's consent.

Music Therapy

I would like to access the following services:

Music Therapy - Initial Consultation

Music Therapy - Consultation

NDIS Supported Music Lessons

I will be accessing the services through:

Child Contact Details

Child's Full Name

Date of Birth

Month

Day

Year

Diagnosis or relevant health or medical conditions.

What goals would you like to focus on in music therapy?

Getting to know your child

Part A: Background knowledge of your child

Describe your child’s mobility and motor skills (such as gross motor, fine motor, coordination, balance, fatigue)

Describe your child’s cognitive skills (such as attention, information processing, memory, auditory and visual processing, listening skills)

Describe your child’s communication skills to express their needs (such as verbal, non-verbal, expressive and receptive language, or methods already in place)

Describe your child’s social skills (such as play skills, interest in others, challenges or barriers to forming and maintaining relationships, joint attention, turn taking)

Part B: Finish the following sentences as if your child is answering them.

Who completed this section?

When I hear music, I...

I express what I want and what I don’t want by…

I feel safe and learn new things is by...

Parent/Carer's Details

Parent/Carer Name

Relationship to the Child:

Mobile

Email

I have read and understood the Terms & Conditions and disclosed any relevant health or medical condition of the client.

SIGN-UP FORM

Music Therapy Sign-up Form

Confidentiality Statement

Music Therapy

Child Contact Details

Getting to know your child

Parent/Carer's Details

Opening Hours

Site Links

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