Recreation Therapy Assessment Sample 444a5w

Recreation Therapy Assessment Patient Name: Student ID #: Physician:

ission Date: Date of Birth: Therapist:

Identifying Information: Student is a 17 year old Caucasian female originally from Australia. Student has long blonde hair, 5' 6", 145 lbs. Diagnosis Axis 1: Autistic Spectrum Learning Disorders, not otherwise specified Attention Deficit Hyperactivity Disorder Rule out Mood Disorder Physical Restrictions/Precautions: MD has placed no physical limitations on std's participation in rec therapy Allergies: Experiences welts with Cephalexin, Ibilix Antibiotic Experiences hallucinations/hyperactivity with Codiene Experiences hyperactivity with Phenegren Inappropriate sinus tachycardia: Recommended monitoring of sun exposure, physical exertion, dehydration. Per mother. Interview/Observation Appearance: Disheveled, wearing baseball cap, clothing had logo on it that a younger person would wear. Clothing not age-appropriate. Behavior Description: During the brief discussion about recreation therapy, student was engaging and congenial although often took control of the talking. She had difficulty letting other people do the talking.

Resources     

Home is located in area with adequate leisure resources, mother is invested in providing adequate opportunities for daughter's treatment Family has adequate financial resources Mother is emotionally attached to child, although somewhat enmeshed Brothers seem ive of student Student has many interests in leisure activities

Recreationl/Leisure Interest and Experience Inventory Sports: Interested in:            

rugby soccer basketball swimming horse-riding sports cricket running dancing mixed martial arts kickboxing/boxing golf tennis

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Has not participated in any sports Enjoys watching most sports

Outdoor/Adventure Activities: Interested in:            

4-wheeling scuba diving camping fishing hiking boating/tubing hunting snowmobiling gardening going to the beach horse-showing environmental studies

Music/Dance/Drama/Literature:      

likes singing individually likes being the lead singer in a group loves acting likes reading war, history, supernatural, and romance genres likes writing stories and poetry listening to music

Arts/Crafts/Cooking: 

likes cooking cultural foods

Social Activities/Travel/Hobbies: In her free time student enjoys:                   

barbecuing/visiting with friends reports liking small social functions, but not large ones fascinated with hairdressing/cosmetology horse-riding cooking dance classes clothing design singing dining out going for walks going to movies/watching TV (especially documentaries) sitting and thinking playing with animals internet cleaning shopping karate/tae kwon do, tai chi fitness: yoga, pilates, kickboxing, MMA enjoys and desires traveling to all parts of the world

Strength/Assets:     

confidence that she is proficient in activities she has participated in attention to detail ability to remain engaged in a single activity for an extended amount of time willing to be assertive to peers has a desire to serve underprivileged or disabled populations/participate in a greater good

Summary: Leisure/Recreational Profile: Student reports enjoying many varied sports and activities but has little to no participation in many of them. Life Style Changes Needed Unhealthy Leisure Values (drugs, crime, etc.):    

No sexual involvement No drug/alcohol abuse No hx of running away Hx of violent behavior when off her risperdal medication

Emotional Needs (self-esteem, impulse control, anxiety, etc.): Std. has difficulty controlling anxiety resulting in poor social skills, especially building relationships. Std. often experiences paranoia and obsessive behavior, requiring validation and feelings of safety from those around her.  

Verbally abusive to peers and adults that set limits Uncooperative with peers and adults that set limits

Limitations:    

Sleep impairment Autism spectrum Inappropriate Sinus Tachycardia Learning Disorder

Findings Family: Findings per mother               

Mother relates possible issues due to marital divorce Mother and biological father divorced over 2 yr time, complicated with criminal court involved Much time taken away from std. during divorce Little to no relationship with stepfather due to his own issues and lack of time Stepfather disregards her Autism and is short and controlling with her Unhealthy living environment with stepfather Has deep love for brothers, especially _______who visited often in Australia. Did not see brother _______ as often. Mother and biological father experienced abusive (verbal and emotional) relationship. Mother left when std. was 3 yrs old. No hx of sexual abuse Did not meet walking developmental milestone within appropriate limits Difficulty sleeping since birth Mother relates constant talking/conversation since a young age Biological father had ADHD, depression, and possibly schizophrenia Brother _______ diagnosed with ADHD One of half-brothers diagnosed with personality disorder, ADHD, conduct disorder, Asperger's; other half-brother diagnosed with ADHD

Social/Emotional     

Ability to make friends but cannot maintain those friendships Lack of discernment and timing when talking to others Inability to accept mistakes of others Often takes things the wrong way No consideration of other's personal space

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Often emotionally immature

Educational         

Hx of tardiness at school Lack of organization skills Attended Spectrum Academy, received help there Hx of physical, verbal abuse by peers, teacher, and principal Gang attacked in 6th grade by peers; no assistance from teachers during attack Changed schools 4-5 times due to constant bullying Testing indicated math disability Attended Huntington Learning Center for tutoring Attended social skills/speech therapy classes when young

Behavioral                            

Sensitive and negatively interprets others comments, leading to paranoia about others disliking her Hx of meltdowns when given such as being told no Inability to task at hand Often bullies, threatens, intimidates others Often loses temper Deliberately annoys people Blames others for behavior/mistakes Often touchy/easily annoyed by others Actively defies/refuses with adults rules/requests Accelerated heart rate Sensations of shortness of breath or smothering when anxious Chest pain or discomfort when anxious Nausea or abdominal distress when anxious Dizzy/faint when anxious Easily fatigued Difficulty concentrating Irritable, irresponsible Complains of muscle tension Sleep disturbance, difficulty staying asleep Identity disturbance Impulsive in spending, inability to recognize consequences Intense mood shifts Chronic feelings of emptiness Hx of intense anger Overeats Low energy Low self-esteem, uses physical appearance to draw attention Feelings of hopelessness

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Anhedonia Significant weight loss/gain when dieting Shows signs of grandiosity, fantasies of unlimited personal success, arrogant behavior Perfectionism Entitlement More talkative than normal Easily distracted Paranoia Bears grudges Lacks close friends Easily influenced by others/circumstances Lacks empathy Hx of hoarding Rigidity/stubbornness

Goals/Plans 1. Student to participate in social/group/leisure education/experiential groups to be held 4 xs weekly. 2. Student to participate in quarterly family experiential sessions or random experiential family visits. Objectives/Interventions 1a. Std. will initiate inclusion and acceptance of peers during RT sessions. This will be evidenced by the Std. refraining from being rude or condescending toward any participants. Std. will not require any staff prompts or confrontations during RT sessions. 1b. At least once per session, and at any time when negative emotions arise, Std. will identify and share emotions with the group. To grasp a wider view of her emotional experience, Std. will verbally identify the thoughts that contributed to her negative emotions. She will demonstrate that she has replaced those negative thoughts by verbalizing a more constructive thought which could include positive thinking and positive affirmations. Std. will require no staff prompts to self-initiate the sharing of her emotions. 2. During RT family sessions, std. will treat family with respect and dignity. Communication will be open, transparent, and ideas will be shared in a mature manner. Std. will take ability for her actions and behavior and will allow family to advocate for themselves. Std. will not require any prompts from RT therapist to extinguish blaming, belittling, anger, etc.

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