Music Therapy Initial Assessment

Note Type: Music Therapy Initial Assessment

Date/Time: [Date and time of assessment]

Location: [Unit / Room / Telehealth]

Therapist Name and Credentials: [Therapist name and credentials]

Patient Identifiers: [Per facility policy]

Referring Provider: [Provider name and role]

Referral Date and Source: [Date and referral source]

Participants Present: [Patient alone / Family / Caregiver / Nurse / Interpreter / Other]

Consent Status: [Obtained / Declined / Not required]

Referral Reason

[Primary reason for referral and clinical need; timing/setting context; what success would look like per referrer or patient] (Write 3–5 sentences. Lead with the core clinical need such as anxiety/distress management, pain coping, communication support, engagement, behavioral regulation, or procedural support.)

Data Sources and Limitations

• Chart elements reviewed: [Notes, orders, labs, medication administration record, therapy notes]
• Informants consulted: [Patient / Caregiver / Nurse / Provider / Other therapists]
• Assessment constraints: [Limited time / Fatigue / Sedation / Hearing impairment / Language barrier / Isolation precautions / None] (Note impact on assessment scope)
• History/preference reliability: [Reliable / Limited / Not obtained] (If limited or not obtained, state reason)

Relevant History and Context

• Pertinent diagnoses and reason for current admission/visit: [Diagnosis list and current episode rationale]
• Current symptoms affecting participation: [Pain / Nausea / Agitation / Anxiety / Fatigue / Other] (Include severity or scores if available)
• Medications/treatments affecting arousal or engagement: [Sedatives / Analgesics / Antiemetics / Chemotherapy / Other] (Include timing relative to session if relevant)
• Sensory status: [Hearing and vision status, aids, deficits]
• Precautions and safety considerations: [Infection control / Lines-tubes-drains / Seizure precautions / Sound sensitivity / Behavioral risks / Falls]
• Communication supports and interpreter needs: [Preferred language / Interpreter / AAC / Writing / Gestures]
• Psychosocial factors: [Family support, cultural-spiritual considerations, coping style, stressors] (Include only if relevant)
• Prior level of function/therapy involvement: [Baseline independence, prior therapies] (Include only if relevant)

(Omit categories that do not apply. For expected but unobtainable information, note "Not obtained" with reason.)

Music Preferences and Relationship

[Role of music in patient's life and any musical background informing intervention planning] (2–3 sentences summarizing how the patient relates to music for coping, identity, spirituality, motivation, or leisure.)

• Preferred genres/artists/songs/languages/instruments: [Preferred musical content]
• Preferred delivery: [Live / Recorded] [Vocal / Instrumental]
• Preferred musical elements: [Tempo / Volume / Rhythm density preferences] (Include only if relevant)
• Aversions, triggers, or boundaries: [Disliked genres / Overstimulating elements / Trauma associations / Volume tolerance / Religious-cultural restrictions / None reported or observed]
• If patient unable to self-report: [Preference assessment method used and observable indicators of preference] (Use qualified language such as "appeared to prefer" with supporting behavioral evidence.)

Assessment Methods

• Clinical interview topics: [History, goals, coping strategies, symptom patterns, prior therapy exposure]
• Observational methods: [Behavioral observation, physiological monitoring, engagement scales]
• Music-based procedures: [Live music entrainment / Receptive listening trials / Instrument exploration / Call-and-response / Lyric discussion / Singing / Songwriting / Guided imagery]
• Standardized tools and scores: [Tool name, version, score] (Include only if administered)
• Modifications/assistance provided: [Positioning / Sensory modulation / Cueing / Visual supports / Adaptive instruments]
• Omitted methods: [Method omitted and rationale] (Include only if typical method was not used)

Findings: Baseline Functioning and Responses

(For each relevant domain, document baseline in non-music context, responses during music-based activities, strengths, needs/barriers, and objective anchors. Omit domains not assessed or not relevant to the referral.)

Cognitive Functioning

(Include if relevant to referral)

• Baseline (non-music): [Arousal/alertness, orientation, attention span, initiation, memory, sequencing]
• During music activities: [Following cues, sustained attention, anticipation of structure, tolerance of transitions]
• Strengths: [Cognitive strengths observed]
• Needs/Barriers: [Cognitive challenges impacting participation]
• Objective anchors: [Counts, durations, cue levels, specific examples]

Communication Functioning

(Include if relevant to referral)

• Baseline (non-music): [Expressive modality/intelligibility, receptive comprehension, pragmatic/social communication]
• During music activities: [Vocalization, lyric completion, turn-taking, spontaneity]
• Strengths: [Communication strengths]
• Needs/Barriers: [Communication challenges]
• Objective anchors: [Words/utterances, cueing level, success rates]

Psychosocial/Emotional/Behavioral

(Required)

• Baseline (non-music): [Affect/mood, coping/distress behaviors, engagement vs withdrawal, behavioral regulation]
• During music activities: [Affect shifts, self-soothing, agitation changes, willingness to interact]
• Strengths: [Protective factors, interests, supportive relationships]
• Needs/Barriers: [Stressors, triggers, environmental constraints]
• Objective anchors: [Affect ratings, agitation scales, duration of engagement, illustrative quotes]

Physiological/Symptom-Related

(Include when referral involves pain, anxiety, relaxation, respiratory pacing, or procedural support)

• Baseline (non-music): [Pain score and behaviors, breathing pattern, muscle tension, restlessness, fatigue]
• During music activities: [Observable shifts, patient-reported symptom change, timing relative to intervention]
• Strengths: [Physiologic regulation capacities]
• Needs/Barriers: [Medical/symptom factors limiting participation]
• Objective anchors: [Pain scale deltas, respiratory rate, HR, timing/duration of changes]

Motor/Sensory/Functional

(Include if relevant to referral)

• Baseline (non-music): [Gross/fine motor access, endurance, coordination, sensory tolerance]
• During music activities: [Rhythmic synchronization, bilateral use, purposeful reach/grasp, pacing support]
• Strengths: [Motor/sensory assets]
• Needs/Barriers: [Motor or sensory limitations, equipment constraints]
• Objective anchors: [Reps, range, assistance level, cadence, distance]

Music Skills

(Optional; include when it informs intervention design)

• Observed abilities: [Beat/rhythm matching, melodic imitation, breath support, instrumental exploration, improvisation tolerance]
• Frustration tolerance with skill challenge: [Observed tolerance and needed supports]
• Objective anchors: [Accuracy percentages, tempo ranges, duration sustained, assistance levels]

Clinical Impression

[Synthesis linking referral needs to salient findings; whether music therapy is indicated and why; factors affecting prognosis; risks, contraindications, or boundaries for music use] (1–2 paragraphs. Reference observed responsiveness and feasible interventions. Label interpretations as clinical judgment tied to observed evidence. Do not diagnose outside scope.)

Recommendations

• Service type and setting: [Individual / Group] [Bedside / Clinic] [Co-treatment with PT / OT / SLP / Child Life / Behavioral Health]
• Frequency/duration/session length: [Frequency, duration of episode, session length]
• Recommended approaches: [Receptive listening / Live music entrainment / Active music-making / Songwriting / Guided imagery / Environmental music supports / Caregiver-assisted music use]
• Materials/equipment and infection control: [Instruments, speakers, disinfection plan, isolation adaptations]
• Coordination with team: [Communication plan, shared goals, sequencing with procedures]
• Caregiver education plan: [Carryover strategies, safety parameters, content selection guidance]
• Reassessment timing: [At session # / Weekly / At care transition / PRN]

(If consult-only with no ongoing therapy planned, document consultation recommendations and education/referrals provided instead.)

Goals

(Include when treatment is recommended. Organize by problem/domain in descending priority. If baseline is unavailable, include an initial objective to establish baseline on first treatment visit.)

[Problem/Domain 1]

• Problem statement: [Functional need in client-centered terms]
• Baseline: [Baseline performance from assessment]
• Long-term goal: [Functional outcome with timeframe]
• Short-term objectives:
  • [Objective with measurable criteria: counts, durations, rating scales, assistance level]
  • [Objective]

[Problem/Domain 2]

• Problem statement: [Functional need]
• Baseline: [Baseline performance]
• Long-term goal: [Functional outcome with timeframe]
• Short-term objectives:
  • [Objective]
  • [Objective]

Education Provided

• Content: [What music therapy is, how it will be used, home carryover strategies, safety parameters]
• Recipient and response: [Patient / Caregiver / Staff] [Verbalized understanding / Demonstrated skill / Needs reinforcement]
• Recording permissions: [Granted / Declined / Not applicable] (Include only if applicable)

Signature

[Therapist signature], [Credentials] — [Date/Time]