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Recreation Therapy Consult Report (sample)

Submitted by Charles C. Dixon, MS, CTRS

Recreation Therapy Consult Report Charles C. Dixon, MS, CTRS

Patient: Susan Jones (names & content are all fictional)
Date: 3-10-91
Consult Requested by: Dr. Winder
Purpose: Pt unable to trust others for companionship
Instruments Used:
a) Leisure Interest Survey
b) Barriers to Leisure Involvement Scale
c) Perceived Freedom in Leisure Scale, Short Version
d) Interview

FINDINGS

- Interests
Ms. Jones enjoys caring for her horses and Dalmatians. She also enjoys singing, drawing, reading, horseback riding, study of philosophy, and shopping. She reported having lost interest and stopped pursuing her preferred activities the past several months. During her free-time she has been going home and covering up under a blanket. She noted that she had lost interest in caring for her horses during this current period of depression... going several days without looking after her horses. To her, this loss of interest in her horses was significant.

When not feeling depressed, Ms. Jones notes that she is satisfied with her leisure lifestyle and is able to enjoy doing the activities she prefers. Recently, Ms. Jones renewed her interest in singing and began taking a singing class. At one time she had sang professionally but injured her neck and quit when it was too painful to sing. She believes that renewing her interest in singing has been helpful to her emotionally. She also shared that at one time, she use to sculpt for enjoyment but since she has been sculpting professionally, she no longer pursues art as a recreational activity. "I used to work with clay and other medium 30 minutes to an hour each night before I went to bed." Overall interest in leisure activities as endorsed in the Leisure Interest Survey is VERY LOW. She has a sense of helplessness in her leisure.

- Social Interaction
Ms. Jones indicated that she did not have a very good childhood and shared a story of being mistreated by other kids. She also shared that she was raped 15 years ago. She pointed to these two incidents as poignant events that influenced her lack of desire in pursuing close relationships with others. At present and much of her life, her primary source of companionship has been her animals.

- Hopes and Dreams
When asked where she saw herself in five years, she suggested that she sees herself dead from committing suicide. She noted that if her twin sister (who is has cancer) is still alive, she would probably still be alive. But if her sister was no longer alive and she hadn't brought her depression under control, she believed that she would definetly commit suicide... "it wouldn't be an attempt... I would make sure I'm dead." Ms. Jones indicated that she has been fighting her depression for 30 years and at this time she is willing to try anything. She views this admission as very important towards her wellness. During this discussion, each time she talked of her animals, her eyes "lit up" and her voice changed from monotone to excitement. She also talked excitedly of yesterday's ropes course experience in which she climbed a telephone pole and successfully completed the "Pamper Pole" challenge. When talking about the future, she talked about a possible career change working at a zoo.

RECOMMENDATIONS

1) Seek new challenges. With interest indicated in the ropes experience, she may want to purse activities such as rock climbing. She was informed about a local indoor climbing site and given a brochure on climbing programs. Pursuing new challenging activities may help renew interest in her life and add repertoire of healthy coping skills. Over the years, Ms. Jones lost interest in activities that once excited her (art, exercise, and singing). It is important for her to seek new challenges or even explore lost interests from a different perspective. Individuals who have multiple repertoire of leisure skills and interests and seek new challenges often have better coping skills.

2) Ms. Jones needs an improved social support network. She should be given assignments to seek out an acquaintance and invite him/her to eat out or do activities as a first step in furthering relationships.

 

Thank you for your referral.

Charles Dixon, MS CTRS

Recreation Therapist

 

 

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