Waiver Intake Form

Music Therapy Policies Form
Client Name/DOB:*
Client Information
Client Name:*
Preferred Name:
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis:
Date of Birth:*

MonthDayYear
Date
Emergency Contact during session:*
Name and Phone Number
Case Manager's Name*
Strengths/Interests:*
Challenges:*
Music Preferences:*
Songs with special significance:*
Religion/Spirituality preferences:*
Preferred Communication Method (verbal, AAC device, ASL, etc.):*
Behavioral Needs/Risks (Seizures, Falls, etc.):*
Allergies*
Personal Care (e.g. toileting during sessions)*
* we do not assist with toileting during sessions but want to be aware of cues to look for and toileting preferences. If an individual requires assistance with toileting, staff or caretaker must stay on site.
Mobility/Transfer Needs*
Other information you'd like to share:
What are your goals for music therapy? *
(Goals may include areas such as motor skills, social engagement, communication, emotional expression, or any potential areas of need. How can we help you live your best life?)
Client Pick Up Form
Individuals authorized to pick up client:
Please list all names
Parent/guardian pick upFamily member pick up (must be listed above)Individual will walk toCatch-a-RideOther (please specify):
(Please Specify)
Location individual will walk to/Other
Emergency Contact (name and number):

Client Name/DOB:*
Consent to Treatment
I 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 know I may access the Keys for Success HIPAA policy at www.keysmusictherapy.com 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
Name*

First NameLast Name
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*
Virtual/Telehealth Sessions
Keys for Success is excited to offer virtual and telehealth sessions as a complement to music therapy services. While this mode of service delivery will certainly not replace our in-person sessions, we feel this will be a good complement during times in which in-person sessions are not possible. Individuals may switch between in-person and telehealth sessions as needed and preferred. Each mode of service delivery has pros and cons and each decision will be made based on the professional recommendation of the music therapist, with input from the individual’s interdisciplinary support team. Giving consent below 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.

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 telehealth music therapy is available under the HCBS Medicaid waivers only until 10/31/2023 and that Keys for Success will not provide any telehealth services funded by the waiver after this date. 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.
I consent for telehealth sessions to be utilized as part of music therapy servicesI do not consent for telehealth sessions to be utilized as part of music therapy services
Acknowledgement of Receipt of Privacy Notice
By signing below, I acknowledge that I have had the opportunity to review an executed copy of this acknowledgement and a copy of Keys for Success’ HIPAA Policy Notice (available in print or via website: www.keysmusictherapy.com/forms) and agree to Keys for Success’ Use and Disclosure of my protected PHI for treatment, payment and health care options.
Signature of Client or Representative*

Clear
Printed Name*
Date*

MonthDayYear
Date

Client Name/DOB:*
Cancellation Policy
Each client has a specific session time reserved. It is important to attend music therapy sessions consistently in order to progress toward goals and utilize your and your therapist’s time in the best manner. We understand that sometimes issues arise requiring a cancellation of session. If you need to cancel, please be respectful of your therapist’s time and cancel as soon as possible. If a cancellation occurs later than the morning of the scheduled session or if you do not let your therapist know of the cancellation, it will be counted as an unexcused absence. Three or more unexcused absences within a six-month period may result in dismissal from music therapy services with Keys for Success.

Extended absences can be accommodated for instances such as vacation, illness, and extenuating family circumstances. Please talk to your therapist or supervisor at Keys for Success if you need to request an extended absence.

If a therapist needs to cancel, we will try to give you as much advance notice as possible. Please make sure you keep your contact information up-to-date with your therapist. In the event of a therapist cancellation, we may have a substitute therapist (for clients for whom this is appropriate) or offer make up sessions. Initial
Initial*
Mutual Consent for Release of Information
It is an inherent belief of Keys for Success, LLC that in order to promote individual consumer success, the whole team must be involved in proactive supports that can be implemented consistently across environments. To encourage such an approach, permission must be given to circulate important information about this case. This includes any recommendations, written correspondence, formal support plans and medical or psychiatric information that may be shared through written, verbal, or electronic correspondence.

Information may be shared with Interdisciplinary Team Members, Waiver Services Representatives, Health Care Professionals, Parent or Consumer Advocate, Provider Healthcare Billing Portal, School Personnel, Supervisor/Job Coach, and Keys for Success Music Therapy Team Members, Agents (including attorney and accountant), Interns and Students.

If there is any particular information that you would like withheld or persons that you would ask NOT be included in this mutual release of information, please specify in the space provided below. We are not required to accommodate or honor your request, but if agreed to, we will not violate the agreement except for provision of Protected Health Information.
Please include all names (if any)
Consumer or Guardian*

Client Name/DOB:
Media Release Consent
Keys for Success shares photos, videos, and audio of the individuals we serve 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 all uses for photo, video, and audio materials that Keys for Success, LLC may use:
Educational (conference/community presentations, sharing with students, etc.)Research (for reference and/or publication in scholarly journals, books, etc.)Promotional (for use in Keys for Success brochures, website, social media, etc.)No, I do not give permission for any photo, video, or audio use by Keys for Success.
I give Keys for Success, LLC permission to use my/individual's first name.No, I do not give Keys for Success permission to use my/individual's first name.
Please list below any specific restrictions on media use:
Consumer or Guardian Signature*

Clear
Date

MonthDayYear
Date
Individual Rights
Copy of individual rights are provided to families at intake and annually with satisfaction survey

I understand that I may access a copy of the Individual Rights (Click “Know Your Rights!) at www.keysmusictherapy.com/resources-1 at any time. I may also request a written or infographic copy at any time from resources@keysmusictherapy.com.

Please report any violations or complaints to Keys for Success Director, Lindsay Menninger at lindsay@keysmusictherapy.com or 513-535-0810. Any violations or complaints will be processed within two weeks of the complaint.
Initial*
I have read and agree to the above:
Client Name:*
DOB:*
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Music Therapy Policies Form

Client Information

Client Pick Up Form

Consent to Treatment

Liability Release

Virtual/Telehealth Sessions

Acknowledgement of Receipt of Privacy Notice

Cancellation Policy

Mutual Consent for Release of Information

Media Release Consent

Individual Rights