IRe Recreational Therapy Assessment

Latency Age
~alne:
--------------------------------~-Age:
__ D.O.B:
-----

Admit Date:
Evaluation Date: ----

Admit Diagnosis:

Medications/Allergies:

1. Educational History:
a. What grade are you in school?
----------------~----------~---b. Do you like school? ----------------------------------------c. Vvhat do you want to be when you grow up?

2. Have you ever been responsible for chores? If so, What?

3. If you had money to spend, what would you buy?

4. What types of activities do you:

a. Do by yourself?

b. Do with your friends?

c. Do with your family?

5. \Vhat talents do you have?

6. What do you like about yoursel!biggest strength?

7. 'What don't you like about yourselflbiggest weakness?

8. Do you find it easy or hard to make friends?

--------------------------~
9. Have you belonged to any clubs?
--:-----

Gross Motor Assessment

1. Balance on each foot for 5 seconds (eyes open) :

a. Right
Left
Needs Assistance ----2. Balance on each foot for 5 seconds (eyes closed) :
a. Right
Left
Needs Assistance
_
J.
"

Walk heal to toe:

a. 8 steps forward
b. 8 steps backward

4. Tln'ow a ball:

a.
b.
c.
d.

Uses one Hand

Uses two hands
Overhand
Underhand

5. Catches a ball:
a. Used two hands
b. U sed one hand

Examiners observations:

Able
Able

Unable
Unable

Perceptual! Fine l\1.otor Assessment

1. Copy exactly what you see in the top box to the box below .

..

II

2. Look at the picture on the left. Check (x) three objects from those shown on the
light that you see in the picture on the left

Draw a Person

Leisure Interest Survey

1. Circle the activities that you enjoy or would like to try.
Physical
Basketball
Swimming
Soccer
Rollerblading
Riding Bikes
Exercise
Baseball
Football

Co~.mitiye
Puzzles/word games
Reading
Cooking
Videogames
Computer games

EmotionaUCreative Expression
Dance
Art
Music
Poetry

Spiritual
Church Activities
Meditation
Yoga

Social
Visiting F1iends
Shopping
Pets

Other

2. My three FavOlite Activities are?

Individual Recreational Therapy Goals

Check all the areas that apply and circle the three goals that are most impOliant to
you:
__

Feeling better about myself

__

Staying on task

__

Following Directions

___

Improving Sportsmanship

___

Having fun

__

Making and Keeping bends

___

Building trust with others

___

Having enough activities to

do during freetime

__

Controlling temper/anger
appropriatel y
__
Speaking up for myself/being
asseliive
. __ . _ Letting adults take care of me
Improving fitness
. Leaming to cope with stress
Being able to express myself
Leaming cooperation/teamwork
Other:

Recreational Therapist's Observations

1. Appearance
__ appropriate, good hygiene
clothing and/or hygiene slightly
diliy or smelly
__ clothing noticeably spotted and/or lack
of good hygiene draws attention
__ very wrinkled and soiled clothing, poor hygiene

2. Eye Contact
__ good, appropriate
__ looked away occasionally
__ looked away frequently
__ little to no eye contact

3. Attention Span
__ attended to therapist during entire assessment
__ occasionally needed to be cued to pay attention

4. Frustration/Agitation Level
__ participated without
frustration/agitation
__ occasiol1ally fru.strated
__ often frustrated/agitated
__ frustrated/unable to pari.

__

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__ could not get attention and keep. attention

__ patient self-administered assessment

5. Attitude During Assessment

enthusiastic and interested
indifferent
__ hostile but cooperative
__ hostile, uncooperative

6. Apparent Comprehension
__ good comprehension
__ basic comprehension
__ poor comprehension

7. Response Time
__ answered most questions innnediately
needed some thought to come up with answers
_ needed a lot of time to respond
__ did not respond

8. Body Posture
erect
rounded shoulders
slouched, head down
__ limp, unable/unwilling
to pariicipate

Strengths:

\Veaknesses:

Recreational Therapv Summary

Evaluation Results:

Recreational Therapy Goals:

Treatment RecOlIDnendation/Approaches:
Provide structured, age recreation therapy, phvsical education, art education, play therapy
and cOlIDnunity settings for patient to work on above stated goals as behavior allows.
Provide encouragement and feedback aspatient makes progress in sociaL emotional,
cognitive, spiritual, and physical domains of development. Encourage patient to express
feelings during recreation therapy activities and in the milieu.
Specific Recommendations:

Recreational Therapist Signature