Individual:                                                                                                                       

Diagnosis:                                                                                                                       

Personal strengths:_____________________________________________________
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Presenting Problem(s) and Needs:                                                                                   
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Sources of information, including instruments used:                                                           
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Assessment instrument findings:                                                                                        
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Leisure Interests:                                                                                                             
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Assistive Technology/Adapted Equipment Needs:                                                            
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Current medications and possible side effects:  
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Recommendations for Therapeutic Recreation Services:  
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Precautions and/or Contraindications for Services:                                                            
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Short term goal(s) and objectives:                                                                                     
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Long term goal(s) and objectives:                                                                                     
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Therapist Signature:                                                                         

Client signature:                                                                            

Date