BEYOND WORDS Music & Dance Center 19448 Blue Spruce Drive, Strongsville, OH 44149 [email protected] / (734) 646-9192 https://www.beyondwordscenter.org

Student Intake Form We're so excited to begin our partnership with you! Beyond Words prides ourself in looking at each student as a whole person. To ensure we have the information we need to best serve our students, please complete the following form with as much detail as possible. It will take approximately 30 minutes to finish. If you have any questions, please feel free to contact us at any time. Thank you!

Contact Information

INTAKE DATE

STUDENT NAME

BIRTHDATE

GENDER M

DIAGNOSIS F

PARENT/GUARDIAN NAMES

ADDRESS

CITY

HOME PHONE

CELL PHONE

EMAIL

PREFERRED CONTACT METHOD Home Phone

Cell Phone

Other DOES THE STUDENT HAVE SIBLINGS? NO YES, Please list names & ages. REFERRED BY

Text

E-mail

ZIP CODE

General Information WHAT PROGRAM ARE YOU INTERESTED IN REGISTERING FOR? (Click all that apply.) MUSIC THERAPY SESSIONS

ADAPTED MUSIC LESSONS

BALLET/TAP COMBO DANCE CLASS

KINDERGARTEN READINESS DANCE CLASS

YOGA DANCE CLASS

DANCE SAMPLER CLASS

PRIVATE DANCE CLASS WHAT DURATION OF SESSION, LESSON, OR CLASS ARE YOU INTERESTED IN? (Click all that apply.) 30 minutes

45 minutes

60 minutes

I don't know.

AVAILABILITY - DATES Mon

Tue

AVAILABILITY - TIMES Wed

Thu

Fri

YOUR REQUESTS, EXPECTATIONS AND GOALS REGARDING MUSIC AND/OR DANCE PROGRAMMING.

IS THE STUDENT ON ANY MEDICATIONS? NO YES, Please list. DOES THE STUDENT HAVE ANY ALLERGIES OR SENSITIVITIES? NO YES, Please list. ARE THERE ANY PRECAUTIONS I SHOULD TAKE IN WORKING WITH THE STUDENT? (i.e. seizures, biting, etc.) NO YES, Please define.

Music & Dance HAS THE STUDENT EVER BEEN IN MUSIC THERAPY BEFORE?

MUSIC LESSONS?

NO

NO

YES, Where?

YES, How long?

HAS THE STUDENT HAD ANY OTHER MUSICAL (band/choir) OR DANCE EXPERIENCE? NO YES, Please define. DO YOU BELIEVE THE STUDENT HAS ANY PARTICULAR MUSICAL APTITUDE, SKILLS OR ABILITIES? NO YES, Please define. ARE THERE INSTRUMENTS IN WHICH HE/SHE IS PARTICULARLY INTERESTED? PIANO

GUITAR

DRUM SET

PERCUSSION INSTRUMENTS

OTHER HOW DOES THE STUDENT RESPOND TO MUSIC? DANCE

SING

PLAY INSTRUMENTS

LIST THE STUDENT'S FAVORITE STYLE OF MUSIC.

LIST THE STUDENT'S FAVORITE ARTISTS OR SONGS.

ARE THERE ANY MUSICIANS IN THE STUDENT'S IMMEDIATE FAMILY? NO YES, Please list.

Academic WHAT SCHOOL DOES THE STUDENT ATTEND?

CURRENT GRADE

DOES THE STUDENT HAVE AN IEP (Individualized Education Plan)?

IS THE STUDENT MAINSTREAMED?

YES

NO

YES

DOES THE STUDENT PARTICIPATE IN ANY OTHER THERAPIES? NO YES, Please list. DOES THE STUDENT MATCH COLORS? YES

NO

VERBALLY LABEL COLORS? YES

NO

DOES THE STUDENT UTILIZE ONE-TO-ONE CORRESPONDENCE WHEN COUNTING? YES

NO

NO

DOES THE STUDENT IDENTIFY AND LABEL NUMBERS? YES

NO

LETTERS? YES

NO

DOES THE STUDENT READ? NO YES, At what level? DOES THE STUDENT WRITE OR PRINT INDEPENDENTLY? NO YES, With which hand? DOES THE STUDENT HAVE DIFFICULTY ORGANIZING SCHOOL WORK? NO YES, Please describe. DOES THE STUDENT USE A VISUAL SCHEDULE WITH ICONS/GRAPHICS? YES

NO

WRITTEN SCHEDULE? YES

NO

PLEASE IDENTIFY THE STUDENT'S ABILITY TO FOLLOW DIRECTIONS INDEPENDENTLY. (Check all that apply.) ONE STEP DIRECTIONS TWO STEP DIRECTIONS THREE STEP DIRECTIONS MULTI-STEP/COMPLEX DIRECTIONS DOES THE STUDENT HAVE DIFFICUTY MAINTAINING ATTENTION TO DIRECTIONS AND TASKS? NO YES, Please describe.

Gross & Fine Motor HAVE YOU NOTICED THAT THE STUDENT HAS HAD ANY GROSS MOTOR DIFFICULTIES? NO YES, Please define. IS THE STUDENT FULLY AMBULATORY? YES NO, Please define. DOES THE STUDENT REQURE PHYSICAL ASSISTANCE? NO YES, Please define.

DOES THE STUDENT HAVE FULL USE OF ALL HIS/HER LIMBS? YES NO, Please define. HAVE YOU NOTICED THAT THE STUDENT HAS ANY FINE MOTOR DIFFICULTIES? NO YES, Please define. IS THE CHILD ABLE TO PERFORM FINE MOTOR TASKS WITH BOTH HANDS? YES NO, Please define. DOES THE STUDENT FREQUENTLY DROP ITEMS OR HAVE DIFFICULTY HOLDING OBJECTS? NO YES, Please define. HAS THE STUDENT BEEN DIAGNOSED WITH HIGH/LOW MUSCLE TONE? NO YES, Please describe.

Expressive Communication HAVE YOU NOTICED THAT THE STUDENT HAS ANY SPEECH OR LANGUAGE DIFFICULTIES? NO YES, Please define. DOES THE STUDENT COMMUNICATE VERBALLY? YES

USE AN AUGMENTATIVE COMMUNICATION DEVICE?

NO

YES

NO

DOES THE STUDENT COMMUNICATE USING SIGN LANGUAGE? YES

NO

DO YOU EASILY UNDERSTAND THE STUDENT? YES NO, Please define. DOES THE STUDENT HAVE ANY IDIOSYNCRATIC SPEECH? NO YES, Please define. DOES THE STUDENT SPEAK IN COMPLETE SENTENCES? YES

NO

MAKE INDEPENDENT COMMENTS? YES

NO

DOES THE STUDENT ANSWER QUESTIONS? YES

ASK QUESTIONS?

NO

YES

NO

DOES THE CLIENT ENGAGE IN BACK AND FORTH CONVERSATIONS? NO YES, How many exchanges?

Receptive Communication/Auditory Perception HAS THE STUDENT BEEN DIAGNOSED WITH ANY HEARING DIFFICULTIES? NO YES, Please define. DOES THE STUDENT HAVE DIFFICULTY HEARING SOUNDS OR UNDERSTANDING SPEECH? NO YES, Please define. DOES THE STUDENT HAVE A HISTORY OF EAR INFECTIONS? NO YES, Please define. DOES THE STUDENT UNDERSTAND OR REACT TO WHAT IS BEING SAID TO HIM/HER? YES NO, Please explain.

Emotional DOES THE STUDENT DISPLAY EMOTIONS APPROPRIATELY? YES

NO

DOES THE STUDENT DISPLAY ANY ABNORMAL FEARS OR ANXIETIES? NO YES, Please describe. DOES THE STUDENT ACT OUT, TANTRUM, OR GET ANGRY EASILY? YES

NO

HAS THE STUDENT SUFFERED ANY EMOTIONAL TRAUMA OR RECENT CHANGE IN LIFE CIRCUMSTANCES? NO YES, Please describe.

Social HAVE YOU NOTICED THAT THE STUDENT HAS ANY SOCIAL DIFFICULTIES? NO YES, Please define. DESCRIBE THE STUDENT'S SOCIAL SKILLS WITH PEERS.

DOES THE STUDENT HAVE A SOCIAL GROUP OF AGE-LIKE PEERS? YES

NO

DOES THE STUDENT PARTICIPATE IN CONVERSATION AND PLAY WITH OTHERS? YES NO, Please define. DOES THE STUDENT PARTICIPATE APPROPRIATELY IN GROUP ACTIVITIES? YES NO, Please define. DOES THE STUDENT HAVE ANY PARTICULAR DIFFICULTY IN SCHOOL OR OTHER SOCIAL SITUATIONS? NO YES, Please define. HAS THE STUDENT BEEN INVOLVED IN ANY THERAPEUTIC SOCIAL SKILLS GROUPS? NO YES, Please list. DESCRIBE THE STUDENT'S SOCIAL SKILLS WITH FAMILY MEMBERS.

DOES THE STUDENT INTERACT WELL ON A ONE-TO-ONE BASIS? YES NO, Please define. DOES THE STUDENT HAVE ANY SPECIAL SKILLS OR INTERESTS (baseball, swimming, trains, animals, etc.)? NO YES, Please list.

Sensory

HAS THE STUDENT BEEN DIAGNOSED WITH ANY DEGREE OF VISION LOSS? NO YES, Does he/she wear glasses or contacts? HAS THE STUDENT BEEN DIAGNOSED WITH ANY DEGREE OF HEARING LOSS? NO YES, Does he/she wear hearing aids or get ear infections? DOES THE STUDENT HAVE ANY SENSITIVITIES TO OR EXTREME PREFERENCE FOR PARTICULAR SOUNDS? NO YES, Please define. IS THE STUDENT OVER-STIMULATED BY SOUNDS, LIGHTS OR CROWDS? NO YES, Please define. DOES THE STUDENT HAVE ANY SENSORY PROCESSING ISSUES? (Please check all that apply.) TACTILE DEFENSIVENESS / SEEKING (touch) VESTIBULAR DYSFUNCTION (awareness of body in space) PROPRIOCEPTIVE DYSFUNCTION (planning & maintaining movement) AUDITORY SENSITIVITY / LACK IN SENSITIVITY (sound) Other DOES THE STUDENT RESIST PHYSICAL SUPPORT? NO YES, Please define. DOES THE STUDENT ENGAGE IN ANY REPETITIVE BEHAVIORS? NO YES, Please define. DOES THE STUDENT HAVE ANY FEEDING ISSUES? YES

NO

RESPORATORY ISSUES? YES

NO

Additional Comments

Thank you for completing our Intake Form! We appreciate your time and detail. If we have not discussed programming opportunities, we will contact you within 24 hours.

Client Intake Final.pdf

HOME PHONE CELL PHONE. EMAIL. PREFERRED CONTACT METHOD. Home Phone Cell Phone Text E-mail. Other. DOES THE STUDENT HAVE SIBLINGS ...

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