Music Therapy Consultation/Referral Form-Fearless Voices

Music Therapy Consultation/Referral Form

This form is designed to gain some key knowledge about you/the participant. The information provided helps us determine where the music therapy program should start and support your initial consultation with us. The more questions you answer, the better we can understand your needs. Please also attach any requested documents if you are happy to share them. We store all of your information securely and will never share your details or information elsewhere. We look forward to talking with you soon. Fearless Voices Music Therapy

Participant Information

First Name

Last Name

Date of Birth

Gender

Female

Male

Other

Formal Diagnosis (es)

Do you/the participant currently have challenges with vision/eyesight?

Yes

Do you/the participant currently have challenges with hearing (e.g. current infections, operations)?

Yes

Do you/the participant require physical support to participate?

Yes

Do you/the participant require a translation service?

Yes

Do you/the participant have a Behaviour Support Plan/Practitioner?

Yes

Representative Details

Full Name

Relationship to Participant

Phone Number

Address

Reason for Referral to Music Therapy

How can we support you/the participant?

What are the current presenting challenges for you/your participant? (Please select all that apply and provide comments/examples if possible in the space below).

Speech/Language (e.g. Expressive Language, Non-Verbal Skills, Receptive skills, Self-Expression

Cognitive Processing (e.g. Memory, Attention, Comprehension, Following Directions, Planning)

Emotional (e.g. Expressing/Identifying Emotions, Emotional Regulation, Perspective)

Fine Motor (e.g. Finger isolation skills, Dexterity)

Gross Motor (e.g. Movement, Eye-Hand Coordinator, Coordination, Balance)

Play/Social Skills (e.g. Joint Attention, Turn-taking, Play Skills, Imitation)

Sensory Processing (e.g. Vision, Hearing, Touch)

Behavioral (e.g. Anxiety, Aggression, Withdrawal, Over-Stimulation)

Other (Please comment below)

Describe or give examples of any of the above challenges

Describe or give example of any additional challenges

Musical Preferences

What is your / the participant's favourite music?

What musical instruments do you / the participant play?

Any other information you would like us to know about your / the participant's musical preferences?

Current NDIS / Other Goals

Please provide your NDIS Participant number

Please provide us with details of your current NDIS goals

I would like to upload my NDIS goals

I would prefer not to upload part/all of my plan and will type them below

Upload File

NDIS Goals (if not uploaded)

Please indicate which of your/the participants goals are of priority to you?

You/The Participants Allied Health Team

Please provide the following details of your/the participants current allied health team.

Provider/Support 1 (name, profession, phone, email)

Upload File

Provider/Support 2 (name, profession, phone, email)

Upload File

Provider/Support 3 (name, profession, phone, email)

Upload File

At Fearless Voices Therapy, we like to work collaboratively with you/your participants current support team. Please upload any recent reports from your/the participants support team

Upload File

Do you give permission for us to contact your allied health team about you/your participant?

Yes

Funding/Payment of Services

For invoicing please provide the following details:

Invoice Name, Company Name, Email Address, Phone

Consultation

Thank you for taking the time to complete this form. We will call you in 48 hours to organise an initial consultation meeting. Please note our current prices reflect NDIS therapy rates and are set at a maximum rate of $193.99 per hour. We look forward to meeting you. Fearless Voices Music Therapy