Name:                           
Date :                            

1) What are your current recreation/leisure interests ?
                                                                                                                               
                                                                                                                               
                                                                                                                               

2) What recreation or leisure activities and resources are available to you in your home ?
      ( examples: games, crafts, books, sports equipment, stereo, etc. )
                                                                                                                               
                                                                                                                               
                                                                                                                                

3) List any community-based recreation/leisure activities that you are participating in now or have in the past. (Parks/Recreation, YMCA, YWCA, Fitness Club, Bowling League, etc., )
                                                                                                                               
                                                                                                                               
                                                                                                                               
                                                                                                                               
                                                                                                                               

4) Name (2) community programs/activities you would like to attend/participate in.
                                                                                                                               
                                                                                                                               
                                                                                                                               
  
5) Who do you socialize with ? ( i.e. talk/interact with on a regular basis )

        family                neighbor                  housemate            

        co-worker             staff                  other                     
 

6) What gets in the way when planning recreation/leisure activities ?
(Barriers: money, transportation, knowledge of community resources, etc. )