Music Project Soundscape Enrollment Form

MUSIC PROJECT “SOUNDSCAPE” ENROLLMENT FORM

Please complete the following information:

Participant’s name:Sex:MaleFemale

Today’s date:Ethnicity:

Participant’s date of birth:Age:

Participant’s address:

Participant’s phone number: Participant’s email address:

Participant’s Diagnoses:

Please enclose proof of diagnosis (e.g. a recent neuropsychological report, letter from psychiatrist / psychologist etc.).

Diagnosed by:Date of diagnoses:

Please list all medications your son/daughter is currently taking:

Has your son/daughter completed an IQ test? If yes, what were the scores?

Full scale IQ:

Verbal IQ:

Performance IQ:

Name of test:

Date of test:

Please describe your son/daughter’s experience with music related activities (if any). For example, do they sing, play an instrument, have participated in a music based program before etc. (Please note, it is not necessary for participants to have any experience with music to participate in the program. They do not need to be able to play an instrument, sing etc. Projects they work on will be tailored to each individual’s abilities and interests).

Parent Information:

Parent(s) / Guardian’s name(s):

Parent(s) / Guardian’s address(es) (if different from above):

Parent(s) / Guardian’s telephone number(s):

Parent(s) / Guardian’s email address(es):

How did you hear about the UML Music project “SoundScape”?

Why would you like your son/daughter to participate in “SoundScape”?

Do you have any questions or concerns about “SoundScape”?

Research component of SoundScape: As part of a research component of SoundScape participants and parents are asked whether they would be willing to complete some questionnaires before and after the program, and also whether they would be willing to participate in a discussion group about the program. More details about these will be explained when you arrive for the first session. It is not necessary to participate in this research component if you don’t want to, and your son / daughter can still participate in SoundScape without either them or you answering any of the questionnaires.

MUSIC PROJECT DEVELOPMENTAL PROFILE

Communication Skills

Does your son/daughter:

Never / Sometimes / Often
Initiate a conversation
Take turns in conversation without monopolizing
Avoid interrupting conversation partner
Remain on topic
Make appropriate eye contact
Maintain appropriate personal space
Choose appropriate topics of conversation
Accurately convey messages
Recognize facial expressions of others
Understand sarcasm
Understand when someone is joking
Understand metaphors

Reading and Writing

Can your son/daughter:

Yes / No
Read and comprehend complex text of reasonable length (e.g.
newspaper articles)
Use a dictionary
Write letters to others
Write advanced letters (e.g. business letters)

Socialization

Does your son/daughter:

Yes / No
Have close friends
Have an interest in making friends
Avoid people
Initiate conversations with people
Respond to conversations of others

Behavior

Does your son/daughter:

Never / Sometimes / Often
Exhibit verbal aggression
Exhibit physical aggression
Have temper tantrums / emotional outbursts
Exhibit high level of anxiety
Exhibit high level of frustration
Have preoccupations with objects or activities (please specify below)

Any additional comments: