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Recreation Therapy Assessment

Patient Name:
Student ID #:
Physician:

Admission Date:
Date of Birth:
Therapist:

Identifying Information:
Std. is a 17 year old female, originally from Pennsylvania with long brown hair, 5'3''.
Diagnosis
Axis I: Mood Disorder not otherwise specified
Attention Deficit Hyperactivity Disorder
Rule out NLD
Rule out other learning disorders
Axis II: Diagnosis deferred
Axis III: No acute diagnosis
Axis IV: Psychosocial stressors moderate
Axis V: Global Assessment of functioning: 45
Physical Restrictions/Precautions:
MD has placed no physical limitations on student participation.
Interview/Observation
Appearance:
Hygiene adequate. Facial acne. Hair was clean. Appropriate clothing for age.
Behavior Description:
Flat affect but willing to communicate with this therapist. She was attentive and interactive
during discussion of leisure activity she had previously participated in. Seemed to be trying to
make a connection with this therapist.

Resources
Family has adequate financial resources
Std. lives in an area that has accessible leisure resources
Family seems to be motivated to change
Std. has supportive family
Recreation/Leisure Interest and Experience Inventory
Sports:

Interested in and participates in swimming


Enjoys watching sports during the Olympics
Table tennis

Horseback riding
Baseball
Bowling

Outdoor/Adventure Activities:
Interested in:

Water skiing
Wake boarding
Snow skiing

Music/Dance/Drama/Literature:

Has been forced in the past to be in choirs


Enjoys singing
Has participated in plays in the past but did not enjoy it
Loves to read, mostly fiction, occasionally realistic fiction
Going to plays/concerts
Has past experience in writing music, but does not enjoy it

Arts/Crafts/Cooking:

Thoroughly enjoys any type of art


Past experience in drawing, painting, oil pastel, photography
Interested in ceramics, pottery

Social Activities/Travel/Hobbies:

Reading
Watch movies
Listen to music and sing along
Enjoys traveling, especially in New England
Board games
Sunbathing
Enjoys large social functions
Enjoys learning
Card games
Loves to play with children
Going to/renting movies
Going to library
Flower arranging
Dining out
Watching TV
Religious participation
Visiting museums
Collages

Picnics
Visiting the zoo/playing with animals

Strength/Assets:

Committed to doing things she enjoys


Does not feel committed to things she does not enjoy
Demonstrates leadership abilities
Ability to make and keep friends
Desires close friendships

Summary: Leisure/Recreational Profile:


Std. shows interests in any type of art or cultural experience. She has an interest in participating
in sports and in gaining friendships. Std. will gain exposure to various leadership opportunities.
Life Style Changes Needed
Unhealthy Leisure Values (drugs, crime, etc.):

Self-harm: cutting, head-banging, attempt at hanging


No violent behavior
No drug abuse
No legal involvement
No sexual activity

Emotional Needs (self-esteem, impulse control, anxiety, etc.):

Std. needs to realize, explore, and cope with full range of emotions
Std. needs to realize potential and improve self-image
Low self-esteem
Decrease times in which std. acts like parent towards others
Std. takes on others' emotions

Limitations:
MD has placed no physical limitations on std.
Findings
Family: per mother

Birth mom reports drug use in first trimester


Birth mom reports biological father had violent and mental health issues
Birth mom victim of emotional and physical abuse
Birth mom reports pregnancy was result of rape
Birth mom consumed marijuana and alcohol during pregnancy
Birth mom: hx of borderline personality disorder, ADHD
Birth dad: hx of bipolar, oppositional disorder, paranoia, personality disorder,
drug/alcohol abuse

Biological brother, ____: drug/alcohol abuse, bipolar, violent tendencies, ADHD


Biological brother, ____: Schizo-affective disorder, ADHD, Asperger's, anxiety
Std. reached all developmental milestones within normal limits
Experienced trauma due to neglect and witnessing abuse along with biological brother,
____, when young
Std. reports abuse, mother relates that could be questionable
Std. has two brothers and two sisters not living at home, one sister, ______, at home
Multiple other foster siblings at home
Std. and biological brother, ______, were foster children, then adopted
Little information about biological background
Due to parents involvement in foster care work, there has been much transition with
children moving in and out of home
Parent's relationship has suffered in past due to foster care work
Parent's relationship currently stable, good communication
Struggles to create deep relationships with all at home
Power struggles at home with father, i.e. doing chores
Difficulty conversing with father
Mother relates that std. utilizes her for emotional regulation and executive functioning
Gets along best with older sister, ________
Has power struggles with ____________ and older sister, ________
Often gives non-verbal communication that indicates she does not want to interact with
certain siblings, especially ________
Older sister, _________, tries to build relationship
Envious of _______ social skills
Emotionally dependent on biological brother, _______. Switches from parenting him to
relying on him.
Contact with biological grandparents
No contact with birth mother
Biological brother, _______ also at MLA due to drugs, alcohol
Contact with all members of adopted family

Educational:

Hx of good grades, recently has been struggling in school


Has been working on 10th grade material since March 2013
K-6: Struggled in math, friendships, depression
7-9: Struggled with friendships, discerning inappropriate relationships, difficulty in math,
reading
Currently in 10th: struggling to finish year
Has repeated grades due to being emotionally unavailable to be successful

Social/Emotional:

Social anxiety, especially around girls


No hx of inviting friends home
Emotionally at age of 5: trust vs. mistrust

Adoption issues
Mood issues
Anxiety
Mother relates that std. magnifies reports of abuse from biological family
Mother relates that std. has hx. of hearing voices

Previous Treatment:

Wilderness: January 2013-March 2013 due to self-harm, depression, anger; then went to
Uinta Academy
Uinta Academy just prior to MLA
"Flew under radar"

Behavioral:

Difficulty with personal hygiene


Catastrophizes and uses avoidance to shift responsibility to others
Blames others for her mistakes
Self-harm: head-banging from 10-14 yrs., attempt at cutting, attempt at hanging self
Fly under radar at school
Misrepresents what has happened at home or other treatment
Hx. of raging, then apologizing
Overeats/hides food
Lie, steal
Argues with adults/defies their rules
Easily annoyed
Often angry
Pounding, accelerated heart rate
Shakes when anxious
Shortness of breath, abdominal distress, lightheaded when anxious
Fear of embarrassment
Avoids feared social situations which interferes with daily life
Difficulty controlling worrying, concentrating
Easily fatigued, distracted, influenced by others
Irritable
Unstable self-image
Impulsive spending
Suicidal/self-mutilating behavior
Mood shifts
Chronic feeling of emptiness
Low self-esteem
Difficulty making decisions
Reads threatening meaning into benign remarks
Does not desire close relationships
Lacks close friends
Consistent irresponsibility

Considers relationships to be more intimate than really are


Requires excessive admiration
Entitlement
Lacks empathy
Fears criticism, rejection
Unwilling to get involved with people unless certain of being liked
Difficulty expressing disagreement with others
Unable to discard worthless objects

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.
Objectives/Interventions
1. Std. will create and foster reciprocal relationships by seeing her self-worth through initiating
positive leadership and will utilize proper coping skills i.e. verbally expressing feelings,
advocating for herself, problem-solving. Std. will require no staff prompts.
2. Std. will establish reciprocal relationships with family members by demonstrating ageappropriate behavior such as allowing parents to fulfill their family roles, advocating for self, and
expressing ideas and needs. Std. will not require prompts from staff.

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