Client Intake Paperwork

Before completing the Client Intake Form, please be sure to review the following:

2020 MMT Rate Sheet
HIPAA Notice of Privacy Practices

Client Intake Form

Your Name & Relationship to Client*
Your Phone Number*
Your Email Address*
Client's Name*
Client's Date of Birth*
Client's Home Address*
Billing Address (if different than home)
Preferred Location for Therapy*
Funding Source*
Client's current therapies (select all that apply)
- Speech Therapy
- Physical Therapy
- Occupational Therapy
- ABA Therapy
- Music Therapy (at another location)
- Under care of Psychologist or Psychiatrist
- Other
Does the client or patient have any formal diagnoses? Please list all.*
What would you like for the client to achieve during the treatment process?*
Client's scheduling availability (select all that apply)*
- Monday A.M.
- Monday P.M.
- Tuesday A.M.
- Tuesday P.M.
- Wednesday A.M.
- Wednesday P.M.
- Thursday A.M.
- Thursday P.M.
- Friday A.M.
- Friday P.M.
- Saturday A.M.
Please tell us how you found Metro Music Therapy
HIPAA Privacy Practices (linked at top of page)*
- I have read and reviewed the HIPAA Notice of Privacy Practices
Attendance Policy*
In the event that the client is ill, or that the client needs to cancel a session for any reason, the client will contact the MT-BC at least twelve (12) hours prior to the scheduled session time. If you fail to give notice to your therapist, you will be charged a “no-show” fee of $50 for that session. It is understood that there are emergency situations and illnesses that can occur and these situations will be handled on a case to case basis.
- I agree to adhere to the Attendance Policy outlined above
Illness Policy*
Our therapists work with medically fragile clients, and we do not want to carry any illnesses to other families, infect ourselves, or our own families. Please cancel your therapy appointment if the client is sick. If your therapist is called or notified about the illness at least 12 hours before your scheduled appointment time, you will not be charged a “no-show” fee for your session. Again, it is understood that there are emergency situations and illnesses that can occur and these situations will be handled on a case to case basis. The Board of Health considers the following signs/symptoms as indications of communicable illness/disease: vomiting, diarrhea, rash/swelling, fever over 100◦, sore throat, red or running eyes. Please be sure you or the client is symptom-free for 24 hours before resuming therapy.
- I agree to adhere to the Illness Policy outlined above
Payment Policies*
Please select only ONE option:
- I am responsible for payment and I understand payment is due on a monthly basis. I understand that Metro Music Therapy, LLC, will invoice me via email on a monthly basis and will accept payment by credit card via electronic invoice or by check.
- I am utilizing 3rd-party funding. I understand that I am responsible for tracking the amount of funding that I have available through my 3rd party source. If MMT invoices the 3rd party and the funding has been maxed out, I understand that I am responsible to pay all denied costs in full. MMT WILL INVOICE ME DIRECTLY WITH THE EMAIL ADDRESS I HAVE PROVIDED; I WILL THEN INVOICE THE AGENCY AND PAY MMT DIRECTLY.
- I am utilizing 3rd-party funding. I understand that I am responsible for tracking the amount of funding that I have available through my 3rd party source. If MMT invoices the 3rd party and the funding has been maxed out, I understand that I am responsible to pay all denied costs in full. MMT WILL INVOICE THE AGENCY DIRECTLY WITH THE INFORMATION I LEAVE BELOW.
Photo & Video Release*
Please select only one option:
- I grant permission to Metro Music Therapy, LLC, its employees and agents, to take and use visual/audio images of me/my loved one. Visual/audio images are any type of recording, including but not limited to photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. I agree that MMT owns the images and all rights related to them. The images, NEVER in association with my full name, may be used in any manner or media without notifying me, such as websites, publications, promotions, broadcasts, and advertisements. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them, or to be compensated for them. I release MMT and its employees and agents, including any firm authorized to publish and/or distribute a finished product containing the images, from any claims, damages or liability which I may ever have in connection with the taking of use of the images or printed material used with the images. I am at least 18 years of age and competent to sign this release on behalf of the above party. I have read this release before signing, I understand its contents, meaning and impact, and I accept the terms.
- I do not agree to the above terms and do not give permission to take and use photos of me/my loved one.
*3RD PARTY FUNDING ONLY: Agency Contact Name & Phone Number
*3RD PARTY FUNDING ONLY: Agency Contact Email Address
*3RD PARTY FUNDING ONLY: Annual Funding Limit
*3RD PARTY FUNDING ONLY: Funding Expiration Date
*3RD PARTY FUNDING ONLY: Are you using this funding for other therapies?
- Yes
- No
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