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
Ethnicity
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Language Spoken at Home
*
