"Initial Intake"
Music Therapy & Art Therapy Wait List
Individual Completing this Intake Form:
*
Please Select
Self
Parent
Legal Guardian
Personal Representative
Service Coordinator
Other
Name and contact information of authorized individual completing the form on the client's behalf:
*
Client Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Client Age:
*
Preferred Name:
Diagnosis/Diagnoses or Presenting Concern:
*
Services desired (check all that apply):
*
Music Therapy-Individual Session
Art Therapy - Individual Session
Music Therapy- Group Session
Art Therapy - Group Session
Site Location Where Services Will Be Provided
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Days/Times Available for Services:
*
Contact Information
If client is a minor, please list parent or guardian's information.
Full Name (if different from client)
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Financial Source
Funding for services will be provided through:
*
CCS
My Choice / Family Care
Private Pay
CLTS Waiver
IRIS
Other
Contact Information for Service Coordinator:
Service Coordinator - IRIS Consultant - Care Coordinator
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Agency
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