Music Therapy Intake Form

Name of Person Completing Form(Required)

Relationship to Child(Required)

Child’s Name(Required)

Birth Date(Required)

Month

Day

Year

Preferred Name

Sex(Required)

Male

Female

Parent/Caregiver 1(Required)

Relation to child(Required)

Phone Number(Required)

Parent/Caregiver 2

Relation to child

Phone Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Please select preferred method of communication(Required)

Phone Number

Cell Phone Number

E-mail

Child lives with(Required)

Both Parents

Mother

Father

Grandparents

Other

Other(Required)

Are there any guardianship/custody issues our office should be aware of?(Required)

Yes

Please explain(Required)

Primary Language Spoken in the Home(Required)

Does your child have siblings?(Required)

Yes

Please List Name & Ages of Siblings(Required)

Adoption Background(Required)

How did you hear about Chatterbox Pediatric Therapy?(Required)

MEDICAL BACKGROUND

Primary Care Physician(Required)

Please list any other doctors and specialists who are involved in your child’s care

Please list any hospitalizations and/or medical procedures or significant family history

Current medications

Name

Dosage

Frequency

Reason for medication

Please list any medical diagnoses

Is your child on a special diet?

BIRTH & DEVELOPMENTAL HISTORY

Was your child carried to full term?(Required)

Yes

If not, how many weeks early was your child born?(Required)

Birth weight

Was your child hospitalized after birth?(Required)

Yes

Vaginal or C-section?(Required)

If there were any complications during the pregnancy or delivery, please provide that information here

Please list corresponding age for which your child reached each milestone

Rolling(Required)

Sitting(Required)

Crawling(Required)

Walking(Required)

First words(Required)

First Sentence(Required)

Did your child ever experience periods of regression?(Required)

Yes

If yes, please explain(Required)

Are there any precautions we should take in working with your child?(Required)

Yes

If yes, please explain here: (i.e. seizures, biting, self-injurious behavior, etc.)(Required)

EDUCATIONAL & THERAPY BACKGROUND

Does your child currently receive other therapy services?(Required)

Yes

If “Yes”, please check which types(Required)

Speech Therapy

Occupational Therapy

Physical Therapy

ABA

Counseling

Other

If yes, please list name and location where therapy services are currently received

Does your child currently attend school?(Required)

Yes

If yes, please list name of school(Required)

What grade is your child in?

Does your child have a current Individualized Education Plan (IEP) or IFSP?(Required)

Yes

If yes, what services are received through the IEP/IFSP?(Required)

MUSIC THERAPY QUESTIONAIRRE

Has your child previously received Music Therapy before:(Required)

Yes

If yes, please list when & where(Required)

Are there any musicians in your family?(Required)

Yes

If yes, who?(Required)

Has your child had any previous musical experience or exposure?(Required)

Yes

If yes, please explain(Required)

Do you believe your child has any musical aptitude?(Required)

Yes

If yes, please explain(Required)

What are your child’s favorite toys/activities?(Required)

Who are your child’s favorite musicians?(Required)

What are your child’s favorite songs?(Required)

What typically calms/soothes your child?(Required)

Who does your child spend most of their time with?(Required)

Is your child currently enrolled in any community activities (music class, sports programs, church/youth group, play groups, Mother’s Morning Out Program)?(Required)

Is there anything we have not covered that you feel is important to share with us?(Required)

Special Needs or Areas of Concern

Gross Motor

Does your child have any gross motor difficulties?(Required)

Yes

If yes, please briefly explain(Required)

Is your child fully ambulatory?(Required)

Yes

Does your child require any physical assistance?(Required)

Yes

If yes, please explain(Required)

Does your child fully use all his/her limbs?(Required)

Yes

If not, please note any limitations(Required)

Fine Motor

Does your child have any fine motor difficulties?(Required)

Yes

Is your child able to perform fine motor tasks with both hands? (i.e. eat with utensils, button a button, hold a pencil)(Required)

Yes

Does your child frequently drop items or have difficulty holding objects?(Required)

Yes

Oral Motor

Does your child have any feeding issues?(Required)

Yes

If yes, please explain(Required)

Does your child have any respiratory issues?(Required)

Yes

If yes, please explain(Required)

Sensory

Does your child have any sensory sensitivities or sensory processing issues?(Required)

Yes

If yes, please explain(Required)

Does your child resist physical support?(Required)

Yes

If yes, please explain(Required)

Does your child engage in any repetitive behaviors?(Required)

Yes

If yes, please explain(Required)

Does your child have any deficits in vision, hearing or any other senses?(Required)

Yes

If yes, please explain(Required)

Does your child have any sensitivities to/or extreme preferences for particular sounds?(Required)

Yes

If yes, please explain(Required)

Receptive communication/auditory perception

Has your child been diagnosed with any hearing difficulties?(Required)

Yes

Does your child have difficulty hearing sounds or understanding speech?(Required)

Yes

Does your child have a history of ear infections?(Required)

Yes

Does your child understand/react to what is being said to him/her?(Required)

Yes

Expressive communication

Does your child have any speech or language difficulties?(Required)

Yes

Does your child communicate verbally?(Required)

Yes

If no, how do they communicate their wants and needs? (i.e. gestures, signs, vocalizations, AAC)(Required)

Do others easily understand your child?(Required)

Yes

Does your child sing along to music?(Required)

Yes

Cognitive

Does your child have any cognitive deficits or difficulties?(Required)

Yes

Is your child with same-aged peers in the educational setting?(Required)

Yes

Emotional

Does your child have any emotional difficulties?(Required)

Yes

Does your child show emotions appropriately?(Required)

Yes

Does your child tantrum or get upset easily?(Required)

Yes

Has your child suffered any emotional trauma or recent hange in life circumstances?(Required)

Yes

Social

Does your child have any challenges in social interactions?(Required)

Yes

Does your child have any difficulty relating to family members?(Required)

Yes

Does your child have a social group of like-aged peers?(Required)

Yes

Does your child participate in conversation or play with others?(Required)

Yes

Does your child have difficulties in school or other social situations?(Required)

Yes

Consent(Required)

I attest that all the above information is true and accurate to the best of my knowledge.

Name(Required)

Date(Required)

Month

Day

Year

Relationship to Child(Required)

FINANCIAL INFORMATION

The following information explains our billing and financial policy for music therapy services. Please contact us at 912-988-1526 with questions about billing/payments.

Most commercial insurance will not pay for music therapy services; however, our billing staff would be happy to assist you with verifying out of network benefits. Please note that a medical referral from your physician deeming music therapy as a medically necessary service may be required to file for out of network coverage. (Aetna, Cigna, UHC most likely to have some OON benefits).

Chatterbox Pediatric Therapy, LLC is not a Medicaid provider for music therapy services.

Music therapy may be considered a qualifying medical expense for Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs). You may also seek reimbursement from your HSA or FSA after paying out of pocket for music therapy services. However, it is ultimately up to your specific HSA or FSA provider to approve payment or reimbursement for services.

Alternative funding sources include the NOW/COMP Waiver, Family Supports Funding
Private Pay rates are also available

Please select how you will be paying for music therapy services(Required)

Private Pay (Must have a credit card on file)

Out of Network Benefits (Patient pays private rate, we will provide you with information to file with your insurance company to apply to OON Benefits, if any)

Medicaid Waiver (Now/COMP)

Family Supports Funding*

Consent(Required)

I agree to the below.(Required)

By signing below, I acknowledge understanding that I am financially responsible for all charges accrued for music therapy services provided through Chatterbox Pediatric Therapy. I understand that Chatterbox is Out of Network (OON) for Music Therapy services with all commercial insurance plans. Should I choose to file for OON benefits through my insurance company, I am responsible for paying all charges for services and will then submit for reimbursement from my insurance company.

I also understand that funding obtained through the Now/COMP waiver or Family Supports Funding is not a guarantee of payment for Music Therapy services. Any balance that is not paid by alternative funding sources will be my responsibility to pay within 30 days of balance accrual.

Patient or guardian signature(Required)

Date(Required)

Month

Day

Year

Medicaid Waiver & Family Supports Funding

Please complete the information below if you will be using Medicaid Waiver or Family Supports Funding

WAIVERS

Are you approved for any Waivers (NOW/COMP)?(Required)

Yes

Name of your waiver case manager?(Required)

Email(Required)

Phone(Required)

Are your waiver funds self- directed or managed by a company?

If managed by a company, please list name of Agency and Address

FAMILY SUPPORTS FUNDING

Have you been approved for Family Supports Funding?(Required)

Yes

Are these funds specifically to be used for therapy services?(Required)

Yes

Are these funds currently being used towards other therapy services?(Required)

Yes