Arizona State University
Music Therapy Clinic
Referral Form
Barbara J. Crowe, Director of Music Therapy at ASU
Robin Rio, Director of Music Therapy Clinic
Sally Niles, Supervising Music Therapist
The Arizona State University Music Therapy Clinic provides music therapy services to a
variety of clients. The equipment and materials fee is $75 per semester, which entitles the
recipient to 50 minutes of goal-based music therapy per week, for a minimum of 10
weeks. Some scholarships are available. Music therapy interventions are provided by an
ASU music therapy student, under the supervision of a Board-Certified music therapist. If
you wish to make a referral to the clinic, please fill out the form below and return to :
Postal address
Robin Rio, MT-BC
Arizona State University
School of Music - Box 870405
Tempe, AZ 85287-0405
Campus phone:(480 )727-6749
Email
Robin.Rio@asu.edu
Client Name______________________________ DOB_________________
Parent/Guardian Name____________________________________________
Email ________________________________________________________
Address_______________________________________________________
_____________________________________________________________
Home Phone_____________________ Work Phone____________________
Presenting Problems/Diagnosis_____________________________________
_____________________________________________________________
List best days and times for sessions:_________________________________
_____________________________________________________________
_____________________________________________________________
For further information, contact Robin Rio at (480) 727-674.