Pediatric Intake Form

Pediatric Intake Form

We look forward to the opportunity to work with your child and family! Please answer the following questions so we can learn more about your child for our first visit. Thank you!
Contact Name*

First NameLast Name
Contact Email*
example@example.com
How did you hear about our services?*
What type of services are you interested in? (Check all that apply)*

IndividualGroupConsultativeOther
Are you planning to use an alternate funding source to pay for services? If so, please specify. (Check all that apply)*

Boone County Family Resources (BCFR)Health Savings Account (HSA)Flexible Spending Account (FSA)Central Missouri Autism Project (CMAP)Private InsuranceNone - I plan to pay private payOther

Availability: Please indicate your child's availability for sessions in the table below. (Check all that apply)*

	Monday	Tuesday	Wednesday	Thursday	Friday
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm

What are your priorities in seeking services for your child?*

Please provide the information for at least 1 parent/guardian
Parent/Guardian Name (1)*

First NameLast Name
Relationship to Child (1)*
Parent/Guardian Email (1)*
example@example.com
Parent/Guardian Phone (1)*
Please enter a valid phone number.

What are your child's favorite songs and/or types of music (i.e. artists/musicians, music genres, etc.)?
Does your child have interest in a particular instrument? If so, please describe.
Has your child received music therapy services in the past? If yes, please describe.

Name of BCFR coordinator, if applicable:
Please describe your child's communication preferences (speech, ASL, assistive device, etc)?*
What typically calms/soothes your child?*
Our clinicians will make recommendations for the duration of services during the assessment process; however, it is helpful to know in advance the duration your child will typically attend (i.e. 15, 30, 45, 60 minutes, etc.). Please describe.

Notice of Action: I understand that while my child is receiving services I may leave the premises. However, I will give my Giving Song clinician a working cell phone number where we can be reached during my absence. In addition, I agree that I will return prior to the end of the session. Late pick-ups may result in additional fees, based on individual situation and frequency. I give consent and permission to Giving Song for any additional treatment or transportation that may be needed in the event that my child is injured or needs medical attention. Also, I understand that the ability to continue to leave the premises while my child is at Giving Song is at the discretion of Giving Song and/or my child’s clinician. I hereby release Giving Song, LLC and any agents or assignees, from any and all claims for damages related to my leaving the premises during my child’s services.*

Yes, I understand and agree.No, I do not agree.
This Consent To Treat Agreement is between Giving Song, LLC and the undersigned as parents/legal guardians of the patient listed above. I do consent for Giving Song, LLC to provide my child with therapeutic services, initial trial sessions, and all other holistic and hybrid therapy/wellness/enrichment services. I consent to care and treatment falling under the practice guideline of the American Music Therapy Association (AMTA), the Certification Board for Music Therapists, and the State of Missouri. I acknowledge that there is always a risk of injury with any service involving physical and emotional activities. This agreement constitutes the entire agreement between the parties regarding the matters contained herein. This agreement may be signed electronically, in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. I understand and agree that they are jointly and severally liable to Giving Song, LLC with regard to all obligations contained within this agreement.*

Yes, I agree to the consent for my child to be treated/served by Giving Song clinicians.No, I do not agree.
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