Intake Form

Intake Policies
Client Name:*
Preferred Name:
Diagnosis (if applicable):
Date of Birth:*

MonthDayYear
Date
Parent/Guardian:*
Phone:*
Parent/Guardian (if applicable):
Phone (if applicable):
Client's Address:
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (during session time):*
Music Preferences (favorite songs/genres, prior music experience, etc.):*
Religion/Spirituality preferences:*
Strengths, interests:*
Challenges including behavioral:*
Risks/Allergies (seizures, falls, allergies, etc):*
Personal Care (e.g. Toileting during sessions):
*we do not assist with toileting during sessions but need to be able to respond to cues that an individual might give. If an individual requires assistance with toileting, staff or parent must stay on site.
Mobility/Transfer Needs:
Preferred Communication Method (verbal, AAC device, etc.):*
What other services, therapies, etc. do you/have you accessed?
Where does the individual go to school, if applicable?
Other information you'd like to share:
What are your goals for music therapy?*
Referred by:
Cancellation Policy
Advanced notice is required for all cancellations. Cancellations made after 9am on the session date will be subject to a $25 cancellation fee, unless the session is rescheduled within one week of original session date. Failure to cancel in advance will result in a 100% charge of the session fee. Repeated cancellations may result in a forfeit of your regular weekly session time.
Initial:*

Client Name/DOB:*
Consent to Treatment
I, *

First NameLast Name
hereby give consent for the above-named individual to receive music therapy services from Keys for Success. This consent is given until I give notice that these services are no longer requested or until Keys for Success notifies me that these services will no longer be provided. I have received the Keys for Success HIPAA policy and understand that all information will be kept confidential. The release of any treatment information will only be granted with a signed agreement stating the name of the third party permitted to review music therapy files. All clients and legal representatives may request to see their files at any time.
Initial*
Liability Release
I fully understand the potential risk of injury common to participating in music therapy and fully assume the risks associated with such participation. I hereby release, and on behalf of the client, I hereby release, Keys for Success, LLC and it’s officers, directors, employees, instructors, and independent contractors from and against and all claims, demands, actions of whatsoever kind of nature, causes of actions, damages, costs, liabilities, expenses or judgments, including, but not limited to, attorney’s fees and court costs and any other liability for any all injury, loss, damage, illness, misadventure and/or inconvenience occurring to the client or arising out of the client’s participation in the programs
Initial *
Media Release
Keys for Success shares photos, videos, and audio of our sessions through printed materials, our website, and social media to share our mission of high-quality music therapy services and to invite others to experience the joy of music therapy. Please select below your preference: I Do / I Do Not give Keys for Success permission to use the individual's photo/audio/video for advocacy, promotional, and educational purposes.
I Do give permissionI Do Not give permission
Restrictions on media use:
Financial Agreement
I,*

First NameLast Name
hereby agree to provide payment for services following receipt of the monthly invoice. I understand that even if I am using third party funding, I will be held responsible for any unpaid balances due to Keys for Success. I give permission for my invoices to be sent via Quickbooks Online accounting software. I give permission for Agents of Keys for Success, including attorney and accountant, to access invoice and payment information.
Initial*
Responsible party name:*
Responsible party address:*
Phone Number:*
Email:*
example@example.com
Relationship to client:*
Which funding source(s) will you use? Please select all that apply.*

Self-payAutism or Jon Peterson ScholarshipSELF or Level One Waiver (PDGS)Family support vouchersOther grant/scholarshipHSAOther

Client Pick Up Form
Individuals authorized to pick up client:
Type a question

Parent/Guardian pick upFamily member pick up (must be listed above)Individual will walk to (please list below)Catch-a-RideOther (please specify below)
Individual will walk to
Other (please specify):
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Virtual/Telehealth Sessions
Keys for Success offers virtual and telehealth sessions as a complement or alternative to in-person music therapy services. Telehealth may be scheduled on an ongoing basis or may be used as an alternative session delivery method during time in which in-person sessions are not possible. Each mode of service delivery has pros and cons and each decision on service delivery will be made based on the professional recommendation of the music therapist, with input from the individual’s interdisciplinary support team. Giving consent does not mean all sessions will be telehealth based but enables telehealth to be utilized when needed. Your music therapist will consult with you on each decision to utilize telehealth.

I hereby give consent for Keys for Success’ music therapists to utilize virtual and telehealth sessions as part of music therapy services. This consent is given until I give notice that these services are no longer requested or until Keys for Success notifies me that these services will no longer be provided. I understand that Keys for Success will maintain confidentiality throughout this service delivery method and I am responsible for confidentiality and privacy at the home or facility at which music therapy occurs.
Parent/Guardian

First NameLast Name
Individual receiving services

First NameLast Name
Telehealth Consent

I do consent to telehealthI do not consent to telehealth
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
I have read and agree to the above policies:
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Intake Policies

Cancellation Policy

Consent to Treatment

Liability Release

Media Release

Financial Agreement

Client Pick Up Form

Virtual/Telehealth Sessions