Client Name____________________ Date: _________________

Individualized Music Therapy Assessment Profile

(IMTAP)
Intake Form

Music Therapist: Katie Corbett MT-BC, MAMT

Date Completed : ____________
(Year, Month, Day)
Client’s Name:________________
Sex: M F
Birth Date: ________________
(Year, Month, Day
Chronological Age: ____________
(Year, Month, Day)
Who is completing this form? ___________________ Relationship to Client:
_________
Guardian’s Phone
Number_________________________________________________
Who will be bringing client to music therapy?
___________________________________

Please note: Questions on this form are of a personal and confidential nature.
Completion of this form is not a requirement for music therapy services.
General Information
Does the individual have a current diagnosis? Yes No
Dx:
Is the individual on any medications? Yes No
Meds:
Does the individual have any allergies or sensitivities? Yes No
Are their any precautions I should take in working with the Yes No
individual?
(i.e. seizures, biting, self-injurious behavior, etc.)
Does the individual participate in any other therapies? Yes No
Therapies:
Has the individual had any previous musical experience or Yes No
exposure?
Do you believe the individual has any particular musical Yes No
aptitude?
Are there any musicians in the individual’s immediate family? Yes No
Who?
Have you noticed the individual has any musical preferences? Yes No

IMTAP adapted from Holly Baxter, Julie Berghofer, Lesa MacEwan, Judy Nelson, Kasi
Peters, and Penny Roberts, 2007
Client Name____________________ Date: _________________

What benefit do you anticipate from music therapy?

Gross Motor
Have you noticed that the individual has any gross motor Yes No
difficulties?
Is the individual fully ambulatory? Yes No
Does the individual require any physical assistance? Yes No
Does the individual have full use of all of his/her limbs? Yes No

Fine Motor
Have you noticed that the individual has any fine motor Yes No
difficulties?
Is the individual able to perform fine motor tasks with both Yes No
hands?
(i.e. eat with utensils, button a button, hold a pencil)
Does the individual frequently drop items or have difficulty Yes No
holding objects?

Oral
Does the individual have any feeding issues? Yes No
Does the individual have any respiratory issues? Yes No

Sensory
Have you noticed that the individual has any sensory issues? Yes No
Does the individual resist physical support? Yes No
Does the individual engage in repetitive behaviors? Yes No
Does the individual have any deficits in hearing, vision, or Yes No
other senses?
Does the individual have any sensitivities to or extreme Yes No
preferences for particular sounds?
Is the individual over-stimulated by sounds, lights, crowds? Yes No

Receptive Communication/Auditory Perception

Has the individual been diagnosed with any hearing Yes No
difficulties?
If so, has an audiogram been done and what were the results?
Does the individual have difficulty hearing sounds or Yes No
understanding speech?

IMTAP adapted from Holly Baxter, Julie Berghofer, Lesa MacEwan, Judy Nelson, Kasi
Peters, and Penny Roberts, 2007
Client Name____________________ Date: _________________

Does the individual have a history of ear infections? Yes No

Does the individual understand or react to what is being said to Yes No
him/her?

Expressive Communication
Have you noticed that the individual has any speech or Yes No
language difficulties?
Does the individual communicate verbally? Yes No
If not please indicate mode of communication:
Do others understand the individual? Yes No
Does the individual have any idiosyncratic speech? Yes No

Cognitive
Have you noticed that the individual has any cognitive deficits Yes No
or difficulties?
Does the individual have an IEP (Individualized Education Yes No
Plan)?
Is the individual in with same-age peers in their educational Yes No
setting?

Emotional
Have you noticed that the individual has any emotional Yes No
difficulties?
Does the individual show emotions appropriately? Yes No
Does the individual tantrum or get angry easily? Yes No
Has the individual suffered any emotional trauma or recent Yes No
changes in life circumstances?

Social
Have you noticed that the individual has any social difficulties? Yes No
Does the individual have any difficulty relating to family Yes No
members?
Does the individual have a social group of like-aged peers? Yes No
Does the individual participate in conversation or play with Yes No
others?
Does the individual have any particular difficulties in school or Yes No
other social situations?
Is there anything we have not covered that you feel is important?

IMTAP adapted from Holly Baxter, Julie Berghofer, Lesa MacEwan, Judy Nelson, Kasi
Peters, and Penny Roberts, 2007
Client Name____________________ Date: _________________

Therapist notes:

IMTAP adapted from Holly Baxter, Julie Berghofer, Lesa MacEwan, Judy Nelson, Kasi
Peters, and Penny Roberts, 2007