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.

Age:

Grade:

Gender Identity:

School:

Type in the School name:

Diagnosis and/or nature of participants needs:

Type of support participant typically receives:

Group / Social Support

1:1 Support

ADL /Medica/ Full Assistance

Upload a photo of the participant here:

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Health Information

Please list any medical conditions staff should be aware of:

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

Yes

Are there any allergies:

Yes

If yes, please list the allergies:

If yes, please elaborate on the medical protocol to be followed in case of an allergic reaction:

Are there any dietary restrictions:

Yes

If yes, please elaborate on the dietary restrictions:

Physical

Does the participant utilize any physical assistive devices?:

Yes

If yes, please check any devices used:

Wheelchair

Walker

Braces

Crutches

Cane

Does the participant have a visual impairment:

Yes

Does the participant have a hearing impairment:

Yes

Does the participant experience any physical limitations that may impact participation (endurance, balance, low muscle tone, gait etc.):

Activities of Daily Living

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

Yes

If yes, please elaborate on the type of assistance that is needed:

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

Yes

Communication

Participant level of communication (please check what applies):

Verbally Independent

Speech Delay

Communication Aid

Sign Language

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

Yes

Cognitive

Is the participant able to follow directions:

Independently

With verbal prompting

With step-by-step assistance

Participant can follow:

1 step directions

2 step directions

3 step directions

Does the participant have a short attention span:

Yes

What setting is most successful for the participant:

Structured

Unstructured

Both

What style of learning is most successful for the participant:

Modeling

Visual Support

Written directions

Verbal prompts

Step-by-step assistance

Can the participant read:

Yes

If yes, does the participant read:

At age level

Below age level

Safety

Is the participant able to stay with a group:

Yes

Does the participant have a history of wandering or bolting:

Yes

Can the participant recognize danger:

Yes

Can the participant manage their own belongings:

Yes

Behaviors

Does the participant get frustrated by others easily:

Yes

Does the participant experience hyperactivity:

Yes

Is the participant typically oppositional/defiant:

Yes

Can the participant manage their own emotions:

Yes

Can the participant control their impulses:

Yes

Does the participant exhibit verbal outbursts:

Yes

Does the participant exhibit any physically aggressive behaviors:

Yes

If yes, towards self or others

Self

Others

Please list any possible triggers for aggressive behavior:

Please describe any warning signs of anxiety, frustration or behavior escalation:

Social

How does the participant socialize:

Initiates social interaction on their own

Socializes with prompting

Avoids social interactions

What does the participant prefer:

Being alone

Being with peers

Being with staff

Does the participant have difficulty sharing or taking turns:

Yes

How does the participant do with transitions:

Great

Not Well

Are there any tools that help the participant with transitions:

What settings is the participant most successful in:

Large groups

Small groups

Both

Does the participant maintain personal boundaries:

Yes

Does the participant understand social cues:

Yes

Sensory

Is the participant sensory seeking or sensory sensitive:

Seeking

Sensitive

Combination

Any additional sensory information:

Tips & Tools

Are there any behavior techniques used at home/school that work well:

What motivates the participant (ex: rewards, positive praise):

What are some interests / likes of the participant:

What are some dislikes or fears of the participant:

What are some of the participants strengths:

What are some areas of improvement for the participant:

Would the participant benefit from any of the following:

Visual Schedule

Reward Chart

Social Story

First / Then Chart

Written Schedule

Verbal Reminders

Timers

Goals

Any additional information you would like to share:

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?

Yes

What type of classroom is the participant in:

Mainstream

Inclusive

Specialized

Does the participant have an aide:

Yes

Does the participant have an IEP:

Yes

If yes, will you be sharing the participants IEP:

Yes

Upload IEP here:

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Does the participant have a behavior intervention plan:

Yes

If yes, will you be sharing the behavior plan:

Yes

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

Yes

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:

Yes

Teacher's Email Address:

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

By signing this form you agree to this information being shared with members of the Lexington Recreation and Community Programs Department.