Music Therapy Referral Form

Music Therapy Referral Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Diagnoses
Medications/Side Effects
Communication - Check All That Apply

HOHUses Hearing AidsWears GlassesBlindAphasic (TBI)Uses Adaptive Communication DeviceOther
Please Explain Other If Checked
Physical - Check All That Apply

WheelchairWalkerCaneAssistance from Staff to TransferImpaired Limb MobilityOther
Please Explain Other If checked
Name of School (If Applicable
Grade
Class

CDCResourceRegular
Emergency Contact (If Different from Above)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred type of communication

Phone CallText MessageEmailMail
Reason for Referral

Quality of LifeEmotional/Mental HealthCognitive/AcademicFine Motor SkillsGross Motor SkillsRange of MotionSensory NeedsAdaptive LessonsCommunicationSocializationStrength and EnduranceAgitation/Behavioral ConcernsCo-teat with other TherapiesOther
Please Explain Other If Checked
Other Therapies Received
Therapist(s) Name and Number - If Co-Treating
Music Background

VocalPlayed InstrumentDancerOtherNone
Please Explain Other If Checked
Preferred Music

PopCountry/WesternCountry PopSpiritual/ ReligiousContemporary ReligiousRapFolkJazzBluesRock & RollClassic RockIndie Pop/RockK-PopHyperpopCulturalPatritoticBluegrassBig Band/SwingR&B / SoulBroadwayClassicalDecade SpecificOther
Please Explain Other If Checked
Favorite Song(s)
Does not like
Other Comments
Scheduling Preferences (if known)
Desired Session Length
Desired Session Frequency
Best Dates and Time or Sessions
Session length and frequency flexible. May adjust session length and frequency to meet person's immediate needs.
Maximum session length if flexible
Maximum session frequency if flexible
Any additional information/requests that may be helpful
Payment (select sevice requested)

Fees: Applicaion/Screening Free $100
Individual Music Therapy Training

$40 / 1/2 hour
Music Therapy Group

RELATE Group: $110/ month (Jackson)MOVE Group: $110/ month (Jackson)SCALE Group: $110/ month (Memphis)
Responsible Payer
Responsible Payer Signature

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After the $100.00 payment is received, you will be contacted by a member of our staff to schedule an assessment. To pay, you can mail cash or a check to 1119 Old Humboldt Road, Jackson, TN 38305. You may also call Misty Hart at (731)554-5150 to pay with a credit card.
Scholarships -If you are interested in applying for a scholarship to partially cover the cost of services please check the box below and we will be in touch.

Yes
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