Music Therapy Assessment
Individual's Name:
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Setting for Sessions:
Cognitive Domain
Attention Span
Rows
Yes
No
Independent
Prompted
Sustains musical activity for length of music
Sustains musical activity for major part of music
Sustains musical activity for short periods
Starts/Stops in response to music
Comprehension
Rows
Yes
No
Independent
Prompted
Participates in song analysis
Participates in lyric analysis
Demonstrates understanding of words of song
Can accurately follow directions
Skills
Rows
DA- Developmentally Appropriate
L- Limited
N/O- Not observed
Reading
Writing
Spelling
Math
Money Skills
Knows Colors
Knows Shapes
Knows Letters
Knows Fast/ Slow
Knows Loud/ Soft
Knows Body Parts
Comprehension Comments
Motor Skills
Upper Extremities
Rows
Yes
No
Assisted
Non-Assisted
Uses left side
Uses right side
Crosses midline
Limited movement
No movement/Impaired
Movement is controlled
Lower Extremities
Rows
Yes
No
Assisted
Non-Assisted
Uses left side
Uses right side
Crosses midline
Limited movement
No movement/Impaired
Movement is controlled
Use of Body
Rows
Yes
No
Assisted
Non-Assisted
Claps Hands
Stomps Feet
Raises Arms
Swings Arms
Bends Knees
Hand Dominance:
Right
Left
Ambidextrous
Fine Motor
Rows
Yes
No
Assisted
Non-Assisted
Opens and shuts palms
Moves fingers independently
Palmar grasp
Pincer grasp
Movement is controlled
Motor Skills Comments
Emotional Skills
Facial Expressions: (Check All that apply)
Alert
Pleasant
Fixed
Tense
Facial Expressions Comments:
Range of Affect: (Check All that apply)
Broad
Flat
Restricted
Changes quickly
Emotional responses match the situation?
Usually
Sometimes
Rarely
Unknown
Emotional responses to music
Related to music
Unrelated to music
No observable response
Emotional Skills Comments:
Social Domain
Awareness of self, others, and environment:
Recognizes own name when sung/spoken
Recognizes names of others when sung/spoken
Sing/Speaks own name
Sings/speaks name of others
Social 1:
Rows
High
Average
Low
Participation level
Impulsivity
Sharing
Joint attention
Social 2:
Rows
Independent
Prompted
NA
Participates for duration
Uses manners
Appropriate greetings
Stays in session area
Turn taking
Social Comments:
Music Domain
Vocal: (Select All that Apply)
Sings on pitch
Follows melody line of song
Sings along with songs
Sings whole phrases
Sings in tonality of the song
Chants isolated words of songs
Chants words and phrases
Chants words of entire song
Chants in rhythm
Chants following tonality
Uses voice expressively
Instruments: (Select All that Apply)
Plays for duration of task
Repeats modeled rhythms
Plays with steady beat
Uses instruments expressively
Matches rhythm to music
Needs help tracking along with the music
Reads adapted music (color coded, by letter, etc)
Preferred Instrument:
History of Music:
Genre preferences: (Select All the Apply)
Country
Pop
Rock
Metal
Christian
Oldies
Hymns
Blues
Electronic
Classical
Hip Hop
Rap
Theater
Jazz
Folk
Reggae
Soul
Punk
Funk
Alternative
Dance
Disco
World
Techno
Ambient
Gospel
Instrumental
Pop Rock
Bluegrass
Ska
R&B
Other
Music Comments:
Recommendations:
Completed By:
*
Please Select
Justine Gibson, MA, MT-BC
Alex Braden, MT-BC
Other
Completed By: (Name & Title)
Signature
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