Therapeutic Recreation Directory

Therapeutic Recreation Referral Form
as used in a nursing home
submitted by Linda Buettner

Therapeutic Recreation Referral Form

"Therapeutic recreation is the provision of treatment services and recreation services to persons with illnesses or disabling conditions. The primary purpose of treatment services which is often referred to as recreation therapy, is to restore, remediate, or rehabilitate in order to improve functioning and independence as well as to reduce or eliminate the effects of illness or disability. The primary purpose of recreation services is to provide recreation resources and opportunities in order to improve health and well-being. Therapeutic recreation is provided by professionals who are trained and certified (CTRS) to provide therapeutic recreation" ATRA 1997

Resident Name_____________Date of referral: ________________

Reason for referral:  ______________________________________

Possible areas for referral:

  • Reduction of symptom levels for chronic or degenerative disorders (reduced pain and stiffness, improved bone and muscle strength, reduced psychiatric symptoms, enhanced overall functioning)
  • Improvement in physical health (physical functioning and fitness; community reintegration)
  • Reduction in health risk factors (risk for falls, decreased body weight, decreased mobility, decrease blood pressure)
  • Improved cognitive functioning (memory, attention span, alertness, problem solving skills, psychosocial skills)
  • Reduction of anxiety, stress, depression, or problem behaviors.
  • End of life care (relief from distressing symptoms through integration of psychological and spiritual care; to help residents live as actively as possible until death)


Priority of problem areas to be addressed:

Referral made by: ________________________________________

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TR assessment completed by: ______________________________

Date assessment completed: _______________________________




M.D. notified and date:

M.D. orders attained: