Skip to form

Recreation and Community Programs Town of Lexington

39 Marrett Road Lexington, MA 02421


Participant Intake Assessment

Form should be completed by participant or guardian and returned to the Recreation Department no later than 2 weeks prior to the first day of program. Please complete all forms thoroughly and accurately as inclusion plans are written based off the information provided in this paperwork, the intake meeting and the Therapeutic Recreation Specialist's assessment of the participant.


Participant Name:

Type of support participant typically receives:

Upload a photo of the participant here:

Click Here to Upload

Health Information

Is there any medication that would need to be distributed during a program:

Are there any allergies:

Are there any dietary restrictions:


Does the participant utilize any physical assistive devices?:

If yes, please check any devices used:

Does the participant have a visual impairment:

Does the participant have a hearing impairment:

Activities of Daily Living

Does the participant need any assistance with any Activities of Daily living (mobility, eating, toileting, dressing, etc.):

Do you give permission for the participant to receive Personal Care Assistance from Lexington Recreation and Community Programs staff?


Participant level of communication (please check what applies):

Does the participant verbally advocate for themselves (needs, wants, feelings):


Is the participant able to follow directions:

Participant can follow:

Does the participant have a short attention span:

What setting is most successful for the participant:

What style of learning is most successful for the participant:

Can the participant read:

If yes, does the participant read:


Is the participant able to stay with a group:

Does the participant have a history of wandering or bolting:

Can the participant recognize danger:

Can the participant manage their own belongings:


Does the participant get frustrated by others easily:

Does the participant experience hyperactivity:

Is the participant typically oppositional/defiant:

Can the participant manage their own emotions:

Can the participant control their impulses:

Does the participant exhibit verbal outbursts:

Does the participant exhibit any physically aggressive behaviors:

If yes, towards self or others


How does the participant socialize:

What does the participant prefer:

Does the participant have difficulty sharing or taking turns:

How does the participant do with transitions:

What settings is the participant most successful in:

Does the participant maintain personal boundaries:

Does the participant understand social cues:


Is the participant sensory seeking or sensory sensitive:

Please indicate if the participant SEEKS any of the following:

Please indicate if the participant AVOIDS any of the following:

Tips & Tools

Would the participant benefit from any of the following:


Please identify any participation goals:

School Information Request

If your child receives support at school, it can be beneficial for the Therapeutic Recreation Specialist to contact their teacher to gain insight on the participants social behavior. This information provided is used to create inclusion plans for participants and ensure staff have adequate information to provide the best support possible to ensure a successful experience for the participant. Do you approve of the participant's school providing this information?

What type of classroom is the participant in:

Does the participant have an aide:

Does the participant have an IEP:

If yes, will you be sharing the participants IEP:

Upload IEP here:

Click Here to Upload

Does the participant have a behavior intervention plan:

If yes, will you be sharing the behavior plan:

Do you consent to the Therapeutic Recreation Specialist contacting your child's teacher via written or verbal communication?:

Do you consent to your child's teacher / aid completing a participant information form? This form contains information regarding the type of support received at school as well as social behavior:

Teacher's Name:

Parent / Guardian Name:

Sign Here

Choose how to sign