Client Intake Form

Looking to learn more about music therapy services for your family member? Please complete the intake form below to the best of your ability. Once you submit this form, our clinical director will contact you to schedule your free phone consultation. If you are seeking contract services or have other questions that you need support, please complete our contact form and we will be in touch. Thank you!

Personal Information

Client Name(Required)

Client Pronouns

Client Sex(Required)

Client Gender Identity

Client Birthdate(Required)

Client Age(Required)

Client Needs and Diagnosis(Required)

Parent / Guardian First and Last Name(s)(Required)

Parent / Guardian Relationship to Client(Required)

Client Sibling Name(s)(Required)

Home Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Primary Phone(Required)

Secondary Phone

Primary Email(Required)

Secondary Email

Emergency Information

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Relationship to Client(Required)

Client Information

Client's Current School or Work Program(Required)

Grade Level / Type of Work(Required)

Does the Client have an IEP, IFSP or 504 Plan?(Required)

IEP

IFSP

504

Other

None

Please tell us about the client's medical needs.(Required)

ie: current medications, precautions, allergies, sensitivities, etc we should be aware of for therapy.

Please tell us about the client’s communication abilities.(Required)

Verbal? Non-verbal? AAC? Sign language? Expressive communication? Receptive communication? Can they answer Wh questions? Open ended? Close ended? Can they ask questions?

Please tell us about the client's social abilities.(Required)

Can they socialize with peers or adults independently or with support? Exhibit other’s awareness? Self awareness?

Please tell us about the client’s cognitive abilities.(Required)

Can they identify numbers, colors, letters, shapes, animals? Pre-literacy? Reading?

Please tell us about the client’s emotional needs.(Required)

Can they identify their own emotions? Can they express them verbally? nonverbally? Can they identify other’s emotions? How do they handle change?

Please tell us about the client’s attention abilities.(Required)

Can the client wait their turn? Can they share with others? Do they utilize flexible seating? What kind? Do they benefit from sensory props or fidgets? What kind(s)?

Please tell us about the client’s behavioral needs.(Required)

Does the client have any triggers? Does the client have any unsafe behaviors we should be aware of? Is the client a flight risk? Is the client prone to self-injury? Other's injury? Is the client continent?

Please tell us about the client’s fine motor abilities.(Required)

Hand dominance? Hand eye coordination? Hand grasp? Pincer grasp? Any significant tone needs?

Please tell us about the client’s gross motor abilities.(Required)

Ambulatory? Independent upper body movements? Bilateral movements (left and right side together)? Can they cross midline? Independent lower body movements? Any motor planning needs we should be aware of?

Please tell us about the client’s music interests and abilities.(Required)

ie: favorite songs, favorites types of music, favorite instruments, bands, singers, dances, etc

Does the client have any adverse reactions to certain sounds, musical instruments or songs we should be aware of?(Required)

Tell us about some things that are motivating for the client.(Required)

ie: positive praise, smiles, high fives, stickers, snack rewards, TV shows, games, movies, etc.

Does the client participate in other therapies or adaptive programs?(Required)

Please list and describe.

Trauma Informed Disclosure

If there is a traumatic event or situation the client has experienced that you would like to disclose to the therapist, please detail it here or in a way that feels most comfortable for you and the client otherwise leave this disclosure blank.

The Groovy Garfoose Policies and Procedures

The purpose of this section is to share our policies and procedures with you upfront. Checking the boxes that you have read our policies and procedures DOES NOT mean you are consenting to services.

Who We Are

The Groovy Garfoose seeks to provide outstanding music therapy services, support and communication to prospective and current clients and their families. We strive to curate a safe and nurturing environment that is accessible, warm, positive and well informed. At the Groovy Garfoose we seek to meet the needs of all people of all abilities in an inclusive and collaborative way with the intention of cultivating self-directed outcomes and growth.

I have read the Who We Are statement.

Therapist Credentials

All Groovy Garfoose music therapists hold the MT-BC credential through the Certification Board for Music Therapists. Board certification credentials can be viewed by logging on to www.cbmt.org and entering your therapist's first and last name. Additionally, All Groovy Garfoose music therapists have completed and cleared FBI / BCI background checks and carry professional liability insurance for personal injury liability, good Samaritan liability, malplacement liability, misconduct of any kind, workplace liability, fire and water liability, personal liability, property damage and information privacy. A copy of your therapist’s insurance certificate can be requested to bonnie.hayhurst@groovygarfoose.com.

I have read the GG credentials as outlined above.

Non-Discrimination Policy

All therapists, interns and staff at The Groovy Garfoose seek to meet the needs of all people of all abilities without discrimination of any kind including but not limited to: sexual orientation, race, color, national origin, gender, sex, age, religion or disability.

I have read the non-discrimination policy.

The Groovy Garfoose Privacy Policy

Privacy is of the utmost importance in therapy. In accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules, yours and the client’s personal and medical information will remain strictly confidential unless authorized with your written consent.

I have read the privacy policy outlined above.

The Groovy Garfoose Payment Procedure

Payment is due upon receipt of monthly bill unless previously arranged with The Groovy Garfoose. Acceptable payments include cash, check, electronic bank check or 3rd party payment. 3rd party payers include FSS, ASP, JPS, PASSS, the SELF-Waiver, and the PDGS of the Level 1 Waiver. Checks should be made payable to The Groovy Garfoose, LLC and mailed to The Groovy Garfoose 4494 Darrow Rd Stow, Ohio 44224. Returned checks for any reason will incur an immediate $25 fee and any associated bank fees in addition to the total amount due.

I have read the payment procedure outlined above.

Good Faith Estimate

Per the No Surprises Act which went into effect on January 1, 2022, you are entitled to receive a “Good Faith Estimate” of the cost for music therapy services at The Groovy Garfoose. While it is not possible to know, in advance, how many sessions may be necessary or appropriate for any given client, we will provide an estimate of the cost of services. Your total cost of services will depend upon the number of months you attend music therapy sessions, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from The Groovy Garfoose nor does it include any services that may be recommended during treatment to you that are not identified in the estimate. The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of music therapy sessions. The number of sessions that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

I understand that I will receive a "Good Faith Estimate" of service costs before I consent to services.

The Groovy Garfoose Attendance Policy

Your consistent and prompt attendance is expected on your designated day and time of therapy unless previously arranged with your therapist. Please notify your therapist at least 24 hours prior to an absence. If you have an early AM session we kindly ask that you call or text your therapist the night before (or text as early as possible that morning) to give them notice of an absence. No shows with no call ahead will incur a full session fee charge. In the case that your therapist is absent for any reason, they will communicate their absence to you as soon as possible and you will not be charged for their absence. Make up sessions are scheduled on a case by case basis.

I have read the attendance policy outlined above.

The Groovy Garfoose Weather Policy

Unsafe weather is unfortunately inevitable in Northeast Ohio. In the case that sessions are canceled on your session day due to unsafe weather conditions or an emergency, your therapist will contact you as soon as possible to cancel your session. You will not be charged for canceled sessions due to unsafe weather conditions or emergencies. Make up sessions for unsafe weather cancellations will be scheduled on a case by case basis.

I have read the weather policy outlined above.

Disclosure

Groovy Garfoose Music Therapists agree to support the client towards set therapeutic goals in music therapy sessions in collaboration with you and the client. By doing so, the therapist will strive to meet the client where they are by building a non-judgmental relationship through which the client can thrive to their highest potential through self-directed and prescriptive music therapy experiences.

I have read the disclosure outlined above.

Termination Policy

Termination will take place when all goals in therapy are met. If you feel that music therapy is not benefiting the client, please notify your therapist and the Groovy Garfoose clinical director sarah.chappell@groovygarfoose.com so changes can be made to meet the client's needs. If you still feel that music therapy is not benefiting the client, you may request to discontinue services to the Groovy Garfoose owner bonnie.hayhurst@groovygarfoose.com at any time. Likewise, your therapist will work with you and the client to combat regression or lack of progress. However, in the case that progress is still not made, your therapist reserves the right to discontinue services as deemed therapeutically appropriate or when ethically necessary.

I have read the termination policy outlined above.

Client Availability

What type of music therapy session are you interested in?(Required)

Individual Session

Peer Session

Social Group Session

What days and times are you available for sessions?(Required)

Please list all days and times, ie: Monday 3pm - 5pm Tuesday 1pm-4pm Wednesday 5-6pm etc...

What do you want the client to get out of music therapy?(Required)

Do you think you may use a 3rd party payment method?(Required)

Check all that may apply.

ASP / JPS

PASSS

County Funds

SELF Waiver

Level 1 Waiver - PDGS

How did you hear about The Groovy Garfoose?(Required)

Check all that apply.

Friend / Family Member

School / Therapy Provider

Social Media

Google Search

Other

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