Therapeutic Recreation Intake Form

  • Therapeutic Recreation Intake Form

    Please fill this form out with the PARTICIPANT THAT WILL ATTEND PROGRAM information. At Danvers Recreation we want every participant to have an opportunity to experience our programs. Julia Ryan is the new Certified Therapeutic Recreation Specialist (CTRS) on our recreation team. Her role is to assist in providing accommodations and services for individuals who may need them to enhance program participation. A meeting may be requested in person to learn more about you/your participant and their needs. Please note that the recreation department may not be able to accommodate every participant's needs, but we will try our best in every case. Please fill out this form in its entirety, the more information the better! Access to confidential information is restricted to authorized personnel and will only be shared with relevant parties as necessary to support care and services. Whether you are the participant, or you are filling this form out on behalf of the participant, please be honest and complete to the best of your ability. This information will be valid for 2 years, unless there is a significant change in any aspect. Reach out with any questions to juliaryan@danversma.gov.
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  • Participant birth date*
     - -
  • Format: (000) 000-0000.

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • General Information

    This section is to provide any information that may allow the CTRS to learn more about the participant and how to provide support in the best way.
  • Has participant been involved in Danvers Recreation before?*
  • Type of support participant typically receives (in school, at home, or other activities). Please check all that may apply:*

  • Health/Medical Information

  • Does participant take prescribed medication?*
  • Does participant experience seizures?*
  • Does participant struggle with mental health?*

  • Physical Information

  • Does participant have any motor impairments?*
  • Please indicate which of the following aids participant uses, if any:
  • Does participant have any visual or auditory impairments?*
  • Does participant require assistance with any of the following activities of daily living (ADLs), please choose all that apply:*
  • In the case of an emergency, please indicate participant's level of independence:*

  • Cognitive Health Information

  • Is participant nonverbal?*
  • How does participant learn best? Please select all that apply:*
  • Can participant read and write? Please check any that may apply:*
  • Can participate read at current grade level?
  • How many step-by-step directions can participant follow when orally given? (Spoken step-by-step instructions)*

  • Behavioral Health Information

  • Does participant have a history or is there a chance of:*
  • Tools used for transitions/breaks/activities? Please check all that apply:*
  • What types of settings is participant UNCOMFORTABLE with? Please select all that apply.*

  • Social and Emotional Health Information

  • Will participant initiate interactions with other children?*
  • Will participant initiate interactions with adults?*
  • Will participant discuss non-preferred topics?*
  • Is participant aware when someone is bullying or when someone is being unkind?*
  • Does your participant have any psychological, emotional, or behavioral concerns that may arise during social situations, new experiences, physical exertion, or stressful circumstances? (Including but not limited to anxiety, aggression, defensiveness, panic attacks, confusion, etc.)*
  • Is participant able to recognize and name emotions?*
  • Does your participant use coping strategies/grounding techniques?*
  • What coping strategies/grounding techniques does participant use?
  • What situations does participant use coping strategies/grounding techniques?
  • Is participant sensory seeking or sensory avoiding?*

  • Teacher/Provider Release

  • Will a private aid, specialist, or therapist accompany your participant to our programs? *Please note we are currently not staffed for a 1:1 ratio**
  • I will provide (or) hereby give permission for my child's teacher to release his/her Individualized Education Plan to the Danvers Recreation Department, (as well as provide written or verbal communication) for use by the CTRS and recreation staff.*
  • I will provide (or) hereby give permission for my child’s provider (ABA therapist, BCBA, Direct Support Provider, etc) to provide written or verbal communication to the Danvers Parks and Recreation Department for use by the Therapeutic Recreation Specialist, Recreation Therapist and Inclusion Staff.*
  • Format: (000) 000-0000.

  • Photo Release Authorization

  • I hereby grant Danvers Recreation permission to use my likeness in photographs, videos, or other digital media in any and all publications, including web-based and print materials, without payment or other consideration. I waive any right to inspect or approve the finished product and release Danvers Recreation from all claims related to the use of these images. I affirm that I am at least 18 years of age, or if under 18, I have obtained parental/guardian consent.*

  • Acknowledgement

    If you are 18 years or younger, please include parent/guardian signature.
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