Music Therapy Assessment Request Checklist

Student Name:______Date of Birth:______

District:______School Site:______

Person Completing Form: ______

These questions may help members of a student’s IEP team to determine the appropriateness of a music therapy assessment. The following questions should be answered prior to referring a student for a music therapy assessment.

Does the student demonstrate specific increased responses when music is incorporated into the following skill areas?

COGNITIVE FUNCTION:

General alertness, attentionyesnosamedon’t know

Attention to taskyesnosamedon’t know

Ability to follow directionsyesnosamedon’t know

Attempting difficult or disliked tasksyesnosamedon’t know

Comprehension of informationyesnosamedon’t know

Sequencing tasksyesnosamedon’t know

Repeating patternsyesnosamedon’t know

COMMUNICATION:

Vocalization/Verbalizationyesnosamedon’t know

Use of gestures and/or signsyesnosamedon’t know

Verbalize/sing to complete familiar phrases yesnosamedon’t know

Verbalize/sing to complete phrases or sentencesyesnosamedon’t know

Sing better than speakyesnosamedon’t know

Speech prosodyyesnosamedon’t know

Vocal volume awareness and controlyesnosamedon’t know

SOCIAL/EMOTIONAL/BEHAVIORAL FUNCTION:

Eye contactyesnosamedon’t know

Remaining in groupyesnosamedon’t know

Taking turnsyesnosamedon’t know

Attempting/completing tasks as modeled by othersyesnosamedon’t know

In seat behaviorsyesnosamedon’t know

Self esteemyesnosamedon’t know

Ability to identify emotions in self and othersyesnosamedon’t know

Ability to process emotions in self and othersyesnosamedon’t know

SENSORY/MOTOR FUNCTION:

Grasps objects/instrumentsyesnosamedon’t know

Uses bilateral gripyesnosamedon’t know

Gross motor movementyesnosamedon’t know

Fine motor skillyesnosamedon’t know

Moves across midlineyesnosamedon’t know

Visual-motor coordinationyesnosamedon’t know

Steady, even gaityesnosamedon’t know

TOTALS yes_____ no_____ same_____ don’t know____

If, after using this form, the IEP team determines that the student is appropriate for a music therapy eligibility assessment, please contact a qualified, board-certified music therapist.

Original form created by Lillieth Grand, MM, MT-BC