Therapeutic Recreation Directory

Therapeutic Recreation Evaluation Form for Adolescent Acute Care Psych


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: ___________________