intake

Client Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DOB *

MM

DD

YYYY

Best Contact Method *

By checking one of the boxes for Best Contact Method, I agree to receiving correspondence from Maestro Music Therapy

Email

Phone

Text

Financially Responsible Party

If different, please complete section below

Same as Client Information

Financially Responsible Party

First Name

Last Name

Relationship to client

Parent

Spouse

Guardian

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact

Please provide at least one

First Name

Last Name

Phone

(###)

###

####

Emergency Contact #2

First Name

Last Name

Phone

(###)

###

####

Referral Source

Friend/Family member

Web search

Practice website

Event

Another provider

Other

Other services currently providing treatment

Physical Therapy

Occupational Therapy

Speech Therapy

Psychotherapy

Art Therapy

Other (please indicate in comment section below)

Acknowledgement:

I, the undersigned, certify that the information above is accurate to the best of my knowledge.

First Name

Last Name

Date

MM

DD

YYYY