Therapeutic Recreation Evaluation Form for Adolescent Acute Care Psych

(sample)

THERAPEUTIC RECREATION EVALUATION
xxxxxxxx Hospital


Name:_______________________________________	Sex: Male/Female		
Age:  _________  Hometown:___________________________________	
Grade in School: ______ 	
Admission Status:  Voluntary/Commitment


Admitting Diagnosis: 	
Medication(s): 	
 
Limitations/Precautions:
Food- 	
Physical- 	
Allergies- 	
Other- 	
	
Parental/Guardian Permission for Activities:  Yes _____  No (list) 	
	

Activity Patterns/Involvement

After School/Summer/Weekends: 	
	
With Family:	
	
With Friends: 	
	
Activities by self: 	
	
Feelings of Boredom and Response: 	
	
Substance Use: 	
	
High Risk Activities including Stealing, etc: 	
	
Exercise: 	
	
Other: 		
	

Leisure/Social Strengths and Weaknesses

Strengths		                             Weaknesses








Signature: ____________________________   Date: ___________________