Hope & Harmony NJ, LLC

Music Therapy Inquiry Form

Caregiver's first & last name

Child's first & last name

Child's birthday

Month

Day

Year

Phone

Address

Formal diagnosis (if applicable)

Please write N/A if your child doesn't have a formal diagnosis at this time.

The following section is to give us an idea of what you are looking for within your child's therapy services. We will complete a more formal assessment upon meeting your child so it's okay to not have the answers at this time!

General areas of functioning you would like to see addressed in therapy

Please select all that apply.

If you answered "Other" above, please specify. Otherwise write N/A.

Are there any specific goals you'd like addressed in therapy? (i.e. improving articulation of speech, increasing attention span, improving a gait impairment)

Please write N/A if you don't have anything specific in mind.

Child's musical preferences, such as songs, artists, instruments etc.

Please write N/A if you are unsure. Don't worry, we'll figure it out!

Please share any other information about your child that may be pertinent to our therapeutic work (i.e. behaviors, motivators, allergies/meds, fears, interests and preferred activities)

Thank you so much for taking the time to fill out this form. We will reach out shortly to discuss everything in more detail.