Written by Ryan Judd

Music Therapy Assessment Request Checklist

The following document is a great place to start if you think your child could be a candidate for a music therapy assessment such as the SEMTAP. 

To download a PDF of this document, please click here.

NAME:                                                                                DATE OF BIRTH:
SCHOOL AND DISTRICT:
FILLED OUT BY:

This form was developed in order to aid IEP teams in determining if a student could be a candidate for a
music therapy eligibility assessment. Please consult with the teacher, parent(s), therapists and other
members of the IEP team and fill out this form based on their responses. Focus on a comparison of
behaviors and skills demonstrated during musical activities versus those demonstrated during nonmusical
activities. Please circle the appropriate response.

        Does the student demonstrate a significantly increased response to music stimuli in the following skill areas?

COGNITIVE FUNCTION:
General alertness, attention                                                                          yes    no     same     don’t know
Attention to task                                                                                          yes    no     same     don’t know
Ability to follow directions                                                                             yes    no     same     don’t know
Attempting difficult or disliked tasks                                                              yes    no     same     don’t know
Comprehension of information                                                                      yes    no     same     don’t know
Sequencing tasks                                                                                        yes    no     same     don’t know
Repeating patterns                                                                                      yes    no     same     don’t know

COMMUNICATION:
Vocalization/verbalization                                                                             yes    no     same     don’t know
Use of gestures and/or signs                                                                        yes    no     same     don’t know
Verbalizing/singing to complete familiar phrases                                             yes    no     same     don’t know
Verbalizing/singing to complete phrases or sentences                                     yes    no     same     don’t know
Sing better than speak                                                                                 yes    no     same     don’t know
Speech prosity                                                                                            yes    no     same     don’t know
Vocal volume awareness and control                                                             yes    no     same     don’t know

SOCIAL/EMOTIONAL/BEHAVIORAL FUNCTION:
Eye contact                                                                                                 yes    no     same     don’t know
Remaining in group                                                                                      yes    no     same     don’t know
Taking turns                                                                                                yes    no     same     don’t know
Attempting/completing tasks as modeled by others                                        yes    no     same     don’t know
In seat behaviors                                                                                         yes    no     same     don’t know
Self esteem                                                                                                 yes    no     same     don’t know
Ability to identify emotions in self and others                                                 yes    no     same     don’t know
Ability to process emotions of self and others                                                 yes    no     same     don’t know

SENSORY/MOTOR FUNCTION
Grasps objects/instruments                                                                          yes    no     same     don’t know
Uses bilateral grip                                                                                        yes    no     same     don’t know
Gross motor movement                                                                                yes    no     same     don’t know
Fine motor skill                                                                                            yes    no     same     don’t know
Moves across midline                                                                                   yes    no     same     don’t know
Visual-motor coordination                                                                             yes    no     same     don’t know
Steady, even gait                                                                                        yes    no     same     don’t know

If after using this form, the IEP team determines that the student IS appropriate for a music
therapy eligibility assessment, please contact a qualified, board-certified music therapist.