Semester_____________________________________
Student______________________________________
Date_________________________________________
WMU Supervisor_______________________________
FORM A
INDIVIDUAL INTAKE & ASSESSMENT
Client:
Name___________________________________________________________________________________
Age______________ Sex_____________ Diagnosis______________________________________________________
Referral Source_____________________________________________________________________________________
Contact Person (if applicable)_________________________________________
Phone number_________________
Treatment Setting:
WMU Music Therapy Clinic__________
Facility (other than WMU Music Therapy Clinic _________________________)
In completing the following, please check all descriptors that apply. There is also space to include additional comments. If
an area is not applicable to your client, write "not applicable or N/A" in that area. If information in an area is not known by
you, write "unknown" in that area. DO NOT LEAVE ENTIRE AREAS BLANK. Each area for assessment must be
completed.
Assessment Setting: - On what are you basing your assessment? (check all that apply):
____clinical interview(s)
____client file
____observation
____interview with family member/teacher/caseworker/previous music therapist
____other__________________________________________________________________________________________
____formal testing (list tests &/or techniques used - see references available in the Music Therapy Clinic &/or your supervisor
for suggestions regarding the use and interpretation of these instruments &/or techniques).
_______________________________________________________________________________________
_______________________________________________________________________________________
1. Presenting Problem: - client's perception of why s/he is in treatment - i.e., client states "....." or the client's family
member's/caseworker's perception of why this client is involved in treatment - i.e., client's father states ".....".
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
___________________________________________________________________________________________
_____unknown
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2. EDUCATIONAL HISTORY: Highest formal school grade completed_____________
Currently attending school____yes ____no If "yes" list:
School name___________________________________________________Grade______
Classroom Experiences
Academic Goals
Teachers Name
____regular classroom
_____________________________________________________________________
____special classroom
_____________________________________________________________________
____music education
_____________________________________________________________________
____unknown
3. EMPLOYMENT HISTORY: Currently employed____
Where___________________________________________
How long?_____Type of work _______________________________________________
Unemployed_____ Comments__________________________________________________________________
_____________________________________________________________________________________________
Retired_____ Comments______________________________________________________________________
_____________________________________________________________________________________________
Disabled_____ Comments________________________________________________________ _____________
_____________________________________________________________________________________________
____unknown ____not applicable
4. MARITAL HISTORY: Currently Single___ Separated___ Divorced___ Widowed___ Co-habitating___ Married___
Therapist Comments_________________________________________________________________________________
_____________________________________________________________________________________________
____unknown ____not applicable
____# of children
____ages
____unknown ____not applicable
5. FAMILY HISTORY: include relevant past history - family dynamics (if known) and current living environment
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_________________________________________________________________________________________
6. MEDICAL TREATMENT HISTORY
Medications
Name__________________________Side Effects__________________________________
How long has the client taken this medication?______________________________________
What is it used for?___________________________________________________________
Name__________________________Side Effects__________________________________
How long has the client taken this medication?______________________________________
What is it used for?___________________________________________________________
Name__________________________Side Effects__________________________________
How long has the client taken this medication?______________________________________
What is it used for?___________________________________________________________
____unknown ____none
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Significant Medical Problems:
___migraine headaches__________________________________________________
___diabetes___________________________________________________________
___cancer____________________________________________________________
___high or low blood pressure____________________________________________
___stroke or paralysis___________________________________________________
___glaucoma__________________________________________________________
___hay fever or asthma__________________________________________________
___heart disease_______________________________________________________
___thyroid disease______________________________________________________
___arthritis___________________________________________________________
___liver disease________________________________________________________
___ulcer_____________________________________________________________
___epilepsy___________________________________________________________
___seizures___________________________________________________________
___allergies___________________________________________________________
___kidney disease______________________________________________________
___lung disease________________________________________________________
___eating disorder______________________________________________________
___sleep pattern disturbance (insomnia, nightmares)
_______________________________________________________________
___other_______________________________________________________________
List any operations the client has had:
_______________________________________________________________________________________
_______________________________________________________________________________________
____unknown ____none
List any major accidents the client has had:
_______________________________________________________________________________________
_______________________________________________________________________________________
___unknown
___none
Client's Family Physician:__________________________________
___unknown ___none
Date of last physical exam:________________________________________________
___unknown ___none
Treatment History
___Outpatient mental health treatment - Dates__________________________________
Explain________________________________________________________________
___Inpatient mental health treatment - Dates___________________________________
Explain________________________________________________________________
___Substance abuse treatment (outpatient or inpatient) - Dates_____________________
Explain________________________________________________________________
___Speech therapy
___Occupational therapy
___Physical therapy
Dates__________________________________________________________________
Explain________________________________________________________________
___Music therapy - Dates__________________________________________________
Explain________________________________________________________________
___Other (explain)_______________________________________________________
-3-
_______________________________________________________________________
___unknown
___none
Current Treatment Involvement [other than music therapy] (list):
___Speech therapy
___Occupational therapy
___Physical therapy
___Group psychotherapy
___Individual psychotherapy
___Self-help support group (topic):
___Substance abuse treatment
______________________________
___Medication monitoring (psychiatric) ___Mobility training
___Vocational rehabilitation
___Other___________________________
___Other:_________________
__________________________________
_________________________
Specific goals being addressed by above treatment:____________________________________
_______________________________________________________________________________________
___unknown ___none
7. COGNITIVE ASPECTS
Orientation
____oriented to time, person, place
____disoriented to either time, person, place
Comments_____________________________________________________________________________
____not applicable
Memory
Recent (short term)
Remote (long term)
____superior
____superior
____adequate
____adequate
____inadequate
____inadequate
Comments______________________________________________________________ ________________
____not applicable
Thought Process
Concentration
____delusional
____restless/unable to sit still
____tangential
____follows therapist's directions
____obsessive
____does not follow therapist's directions
____expresses grandiose ideas
____attentive to task throughout session
____expresses homicidal ideas
____expresses suicidal ideas
____expresses paranoid ideas
____does not attend to tasks
____accelerated thought
____easily distracted
____hallucinations
Comments___________________________________
____clear
____abstract
____concrete
Comments____________________________
____not applicable
-4-
8. PHYSICAL ASPECTS/ MOTOR FUNCTION
Upper Extremity (Arms/ Shoulders)
_____below age/grade level
____RT____LEFT
_____age age/ grade level
____RT____LEFT
Fine Motor (Hand/ Fingers)
_____below age/grade level
____RT____LEFT
_____at age/grade level ____RT____LEFT
Comments___________________________
___________________________________
Gait Parameters
Standing Balance
_____below age/ grade level
Trunk Control
_____below age/ grade level
Cadence
_____below age/ grade level
Stride Length
_____below age/ grade level
Heel Strike
_____below age/ grade level
Comments__________________________
__________________________________
_____at age/grade level
_____at age/grade level
_____at age/grade level
_____at age/grade level
_____at age/grade level
Other______________________________________________________________
_____Not Applicable
9. SOCIAL BEHAVIOR/GROUP BEHAVIOR (based on your observation of the client in a group or social setting or on
their interaction with you in individual therapy sessions):
Participation
Social Behavior
___does not participate
Degree of interaction
___participates actively
___initiates social interaction
___participates passively
___shy/quiet
___cooperates with directions/limits
___isolates self in group
___willing to try new experiences
___refuses contact with peers/therapist
___resistive to trying new experiences
___disruptive/uncooperative
Type of interaction
___able to handle failure with
___considerate of others
adequate coping skills
___not considerate of others
___overly frustrated when unable to succeed
___approachable
___has difficulty with impulse control
___outgoing
___sets up power struggles with
___seductive/flirtatious
peers or therapist
___mature
Comments__________________________
___immature
__________________________________
___controlling
___competitive
___assertive
___aggressive
___destructive to property
___verbally abusive
___uses humor
Comments____________________________
Potential Reinforcers (non-musical)
_____________________________________
Material (food, books, stickers)
_________________________________________________________________________________
_________________________________________________________________________________
source of information______________________________________________________
Social (praise, applause, smile, touch)
_________________________________________________________________________________
_________________________________________________________________________________
-5-
source of information___________________________________________________
Activities (sports, gardening, knitting, painting, watching TV, video games)
_________________________________________________________________________________
_________________________________________________________________________________
source of information__________________________________________________________
10. AFFECTIVE STATE/EMOTIONAL FUNCTIONING
Affect
Attitude
___positive
___age appropriate
___open to influence/reason (open-minded/flexible)
___flat/no facial expression
___not open to influence/reason
___minimal facial expression
___depressed(rigid)
___labile
___hostile
___congruent with verbalization
___sarcastic
___incongruent with verbalization
___overly critical
___appears angry
___demanding
Comments__________________________
___passive-aggressive
__________________________________
___evasive
___guarded
___fearful
___resistive
___blaming
___optimistic
___pessimistic
Comments___________________________
____________________________________
Self-Esteem
___identifies & expresses positive aspects of self
___makes self-depreciating remarks
___accepts positive feedback from others
___discounts positive feedback
___seeks approval from others
Comments_____________________________
Motivation
Degree
___high motivation to change
___some motivation to change
___little motivation to change
Comments:(i.e. Does the client appear to be self-motivated [e.g. client states s/he ready to change, etc.]
and/or externally motivated [e.g. court referred, family insists on treatment, etc.].)
_______________________________________________________________________________
Suicidal Potential (for any response other than "none" see Suicidal Potential Rating Scale in the Music Therapy Clinic
and discuss with your supervisor.)
___none (do not include in Assessment Summary)
___minimal-explain_____________________________________________________
___moderate-explain____________________________________________________
___severe-explain______________________________________________________
-6-
11. COMMUNICATION
Communication
Verbalization
___unable to identify feelings/needs or issues
___spontaneous
___able to identify feelings/needs or issues
___initiates
___difficulty expressing self
___nonverbal
___expresses self freely
___only when prompted
___difficulty writing
___coherent
___difficulty reading
___sometimes incoherent
Comments_____________________
___incoherent
_____________________________
___loud voice
___barely audible voice
___mumbles
___speaks clearly
___excessive or inappropriate verbalization
___brief verbalization
___articulation difficulties
___slurred speech
___stutter
___phonation
___volume (amplitude)
Comments______________________
______________________________
Other communication skills
___sign language
___purposeful gestures/body language
___purposeful gestures accompanied by vocalizations
___computerized communication
___Bliss board
___other_________________________________________________________________________
___none
12. MUSIC-RELATED BEHAVIOR
Music Preference: indicate the types of music the client enjoys with a "yes" and the types the client dislikes with a "no".
___Popular
___Classical (choral)
___Easy listening
___Classical (orchestral)
___Musicals and showtunes
___Opera
___Light rock
___Country
___Hard rock
___Folk music
___Big band (swing)
___Jazz
___Gospel/contemporary Christian
___Hymns
___Rhythm and blues
___Other_______________________
___Rap
___None
___Children's music
___Unknown
Client's favorite songs/artists include (list):
________________________________________
________________________________________
________________________________________
________________________________________
Role of Music in the Client's Life
___as a means to express feelings
___as a recreational/social outlet (interact with others)
___as a method to communicate to others
___as a creative outlet
___as a way to focus thinking
___as a way to escape from life=s pressures (diversion)
___as a reinforcement for beliefs & values
___as an educational tool
___for dancing
___as a way to remember the past
___as a motivator to do work
___not applicable
-7-
___as a way to relax/manage stress
___unknown
___as a parenting tool
___Other
___for fun/enjoyment
Has the role of music changed in the client's life?___no ___yes___not applicable ___unknown
If "yes explain____________________________________________________________
Musical Skills (list)
___sings________________________________
___plays instrument(s) - list
___________________________________how long_________________
___________________________________how long_________________
___________________________________how long_________________
___reads music
___writes music
___other_________________________________________________________
___none
___unknown
Comments______________________________________________________________________________
Observed Affective Response to Music
Music Resources Available to Client
In response to music, the client:
___record/tape/CD player
___cries
___piano/keyboard
___becomes agitated
___other instruments-list
___smiles
__________________________
___becomes engaged (moves, etc)
__________________________
___becomes anxious
__________________________
___becomes relaxed
___walkman
___animated
___music books/sheet music/manuscript paper
___other____________________________
___other____________________________
___none
___none
___unknown
Describe the type of music used to determine the above:
___________________________________________________________________________________________
________________________________________________
___unknown
Client's Expectations Regarding Involvement in Music Therapy - list the client's most favorite/least favorite aspects
of music therapy (if client has had prior experience with music therapy) &/or what the client (or the client's parent)
would like to accomplish (or have accomplished) musically in therapy.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___not applicable
___unknown
-8-
13. TEST RESULTS (if applicable) - indicate below the name of the test(s) &/or the type of technique(s) used in your
assessment of this client and the results. ATTACH ALL TEST MATERIALS TO THIS FORM.
A. test/technique_____________________________________________________
results/interpretation_______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
B. test/technique____________________________________________________
results/interpretation_______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___none/not applicable
14. OTHER: any information you believe is important and is not included elsewhere - i.e., military history, religious affiliation
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
____________________________________________________________________________________________
15.
SUMMARY
Major Areas of Strength (list)
Musical_________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Non-Musical____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Major Areas for Improvement (list):
Musical______________________________________________________________________ ___________
_______________________________________________________________________________________
_______________________________________________________________________________________
Non-Musical________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
16.
RECOMMENDATIONS:
Tentative Individual Goals Include (examples of treatment objectives are indented):
___improve affective state/emotional functioning
___increase self-esteem
___increase ability to identify feelings/needs/issues
___increase resolution of (or awareness of) conflicts related to the client's family of origin
___increase trust/self-disclosure
___increase awareness of sources of depression/anxiety
___decrease depression/anxiety
___increase awareness of sources of anger
___increase ability to appropriately express anger
___other__________________________________________________________
___other__________________________________________________________
___improve physical/motor skills/functioning
___improve gross motor function
___improve fine motor function
-9-
___improve movement functions (axial/locomotor)
___improve balance
___improve psychomotor skills
___improve perceptual motor skills
___increase stress management/relaxation skills
___other__________________________________________________________
___other__________________________________________________________
___improve communication skills
___improve vocalization/speech
___improve ability to express self
___improve amount of verbalization
___other__________________________________________________________
___other__________________________________________________________
___improve cognitive skills
___improve concentration
___increase reality orientation
___improve memory (short term/long term)
___other__________________________________________________________
___other__________________________________________________________
___improve social behavior/social skills
___increase cooperation
___improve leisure/recreation skills
___increase assertiveness
___increase willingness to try new activities
___increase frustration tolerance
___other__________________________________________________________
___other__________________________________________________________
___improve academic skills (list):
________________________________________
________________________________________
________________________________________
___improve musical skills (list):
________________________________________
________________________________________
________________________________________
Do any areas need further assessment? (list):
________________________________________
________________________________________
________________________________________
___none
-10-
Semester________________
Client:_______________________________________
Dates of Assessment:___________________________
Student Therapist:______________________________
WMU Supervisor:______________________________
ASSESSMENT SUMMARY (INDIVIDUAL)
Using the information you have obtained from the observation checklist above (and any tests or interpretive
technique used in your assessment) summarize your assessment of this client in narrative form.
_____is a_____year old___diagnosed with_____. He/She was referred by_____for music therapy. The following
assessment is based on_____and was conducted over a_____period of time.
1. Presenting Problems:
2. Educational History
3. Employment History:
4. Marital History:
5. Family History:
6. Medical Treatment History:
7. Cognitive Aspects:
8. Physical Aspects/Motor Function:
9. Social Behavior/Group Behavior:
10. Affective State/Emotional Functioning:
11. Communication:
12. Music Related Behavior:
-11-
13. Test Results:
14. Other:
15. Summary.
16. Recommendations:
_______________________________
Student Name, Music Therapy Student
_______________________________
Date
-12-