Music Therapy Assessment Tool

Pregnancy Center
Name: _______________________________ __
DOB:________________________________
Date of Assessment:______________________ Number of
Observations:________________

I.

Descriptive Information

II.

Assessment (rank 1(need) or 5(strength))

1. Communication
a. Baby to mother_________________
b. Verbal_____
c. Expressive language______
d. Receptive_____________
Responds to words of songs________
Follows verbal directives____
Executes appropriate actions to words of song_________
e. Articulation______
f. Eye contact_______
2. Cognitive
a. Educated on physical changes__________________________
b. Educated on pregnancy________________
c. Decision making skills______________
d. Educated on benefits of Music Therapy_______________________
e. Recognizes reactions from body/baby____________
f. Preparation for baby__________________
g. Techniques of childbirth_________________
h. Client shares memories as child_____________
3. Physical
a. Ability to Relax__________________
b. Ability to control comfort____________________
c. Ability to comfort Fatigue________________
d. Physical Exercise___________________

e. Physical with music_________________________

f. Recognizes reactions from body/baby____________
g. Massaging with or without music_______________
4. Social
a. Interactions with friends/family______________
b. Interactions with babys father________________
c. Interactions with baby__________________
5. Emotional
a. Range of affect_______________
b. Awareness of emotions______________________
c. Appropriate outlets of emotions______________________
d. Ability to control Depression_________________________
e. Ability to control Anxiety_____________________
f. Ability to deal with fear______________________
g. Ability to deal with Fatigue__________
h. Thoughts of hurting somebody or someone__________
i. Connection to music and body/baby_______________
j. Recognizes reactions from body/baby_____________
6. Musical
a. Physical reactions through song______________
b. Singing and breathing___________________
c. Singing to reduce perception of pain________________
d. Physical reactions through rhythm___________
e. Lyrical Memory__________________
f. Use of Dynamics__________________
g. Singing Volume______________
h. Musical expression______________________
i. Watches for cues____________________
j. Uses music for relaxation_________________
k. Techniques for childbirth______________________
l. List of non-useful Instrumentation
_______________________________________________________________
_______________________________________________________________
III.

Informal Observations
1. Expected or unexpected pregnancy______________
2. Due date___________________________________________
3. Happiness with partner_______________
4. Education________
5. Occupation__________________
6. Trimester_______________________
7. Age_____________
8. Personal Presentation________________

IV.

Interview

V.

Comments
1. Strengths
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________
2. Areas of need
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________
3. Target Behavior
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________
4. Personal Response
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________

Observer:_________________________________
Date:__________________________