MUSIC THERAPY ASSESSMENT REQUEST CHECKLIST

NAME: DATE OF BIRTH:

SCHOOL: FILLED OUT BY:

To determine if a student is a candidate for a music therapy assessment, observe the student in a variety of locations and activities. Focus on behaviors observed with the presentation of live or recorded music compared to behaviors demonstrated without musical stimuli. In each case, consider the following question:

Does the student demonstrate a significant increased response to music stimuli ?

Respond “Yes/No/Same” to all the questions below:

COGNITIVE/ACADEMIC FUNCTION

1. Demonstrates increased alertness, attention (i.e., increased respiration, physical arousal, turns head toward sound source)

2.Attends to task: Approximate length of time

3. Demonstrates increased ability to follow directions

4.Participates in completes difficult or disliked tasks

COMMUNICATION

1. Demonstrates increased vocalization/verbalization

2. Demonstrates use of gestures/ signs

3. Verbalizes/sings single words to complete a phrase

4. Verbalizes/sings complete phrases or sentences

SOCIAL/BEHAVIORAL FUNCTION

1. Demonstrates increased eye contact to staff/peer/parent

2. Remains in group setting for increased duration

3. Takes turns/ shares items

4. Demonstrates increased motivation to complete directed tasks

SENSORY/MOTOR FUNCTION

1.Grasps objects/instruments

2.Moves body in rhythm with music

3. Moves body in bilateral movements (clapping, marching)

4. Crosses midline

Why do you believe a music therapy assessment is necessary for this child to benefit from his/her special education?

(Please include additional comments on the back of this checklist.)

Reprinted with permission from Marcia Behr, MT-BC, 2002

Permission is granted for qualified music therapists to duplicate pages for assessment administration only. No other use or duplication is authorized without written consent from Kathleen Coleman or Betsey Brunk: Prelude Music Therapy.