Counselor's Report

What Camp Session did this individual attend?*

TherapySkills

Camper's Name*

First NameLast Name

On opening day:*

No apparent problems with separation from parents/guardians on opening day.Some problems with separation from parents/guardians on opening day.

If there were problems with separation on opening day, what did that look/sound like? (ex. crying, shut down, refusal)

Episodes of homesickness during the camping session:*

NoneOccasionalFrequent

How did homesickness present during camp? What did it look/sound like? (Ex. change in behavior, crying, talking about home, etc.)

Adjustment to camp routine:*

Camper was familiar with camp routine from previous years.Camper adjusted quickly to the camp routine.Camper took a long time to adjust to the camp routine.Camper did not adjust to camp routine.Camper spent time in refusal.

Daily Schedule:*

Camper was usually punctual to classes and activities and was ready for classes without prompting.Camper required staff intervention to arrive at class and activities on time.Camper missed classes and activities due to refusal.

If camper missed classes and activities due to refusal, how often did this happen?

1 to 2 times over the whole session1 to 2 times a week1 to 2 times a dayFrequent problem, sometimes several times a day

Camper traveled to classes:*

Independently (Could be sent ahead of group or would catch up with group if necessary)Independently with some supervision and guidance (Could be trusted for short periods of time or get to places alone when watched from a distance.)This camper needed to be escorted to classes (without staff intervention, camper would not have attended classes.)

How did this camper adjust to the full schedule? Did they keep up with the schedule and camp activities? Was this camp session a good pace for this camper?

How did this camper adjust to living with cabinmates? (being a respectful cabinmate, sharing space, going to sleep or staying asleep in the cabin, etc.)

What did this camper typically do during rest hour? Did they follow the expected behavior of counselors?

Comments about adjustment to camp.*

Please provide additional information on camper's adjustment to camp or any information that you think would be helpful to caregivers, school or therapy personnel, and/or future camp staff.

Initiated APPROPRIATE conversation with peers:*

FrequentlyOccasionallySeldomNever

Initiated INAPPROPRIATE conversation with peers:*

FrequentlyOccasionallySeldomNever

Interaction with Peers:*

Consistently interacted appropriately with peersNeeded occasional reminders to interact appropriately with peersNeeded frequent reminders to interact appropriately with peers

If this camper needed occasional or frequent reminders to interact appropriately with peers, what types of inappropriate behavior was being exhibited?

Leadership:*

Tended to be a positive influence on cabinmates and peers.Tended to be a negative influence on cabinmates and peers.

Followership:*

Tended to follow positive role models and choose to do the right thing.Tended to follow negative role models and make poor choices.Was not influenced greatly by the behaviors of peers.

Sharing/Cooperation*

Shared and cooperated with peers readilyNeeded reminders to share and cooperate with peers

To what extent did this camper need reminders to share and cooperate with peers? How did this present?

Personal Space*

Respected others' personal space and kept hands to him/herselfOccasionally needed reminders to respect others' personal space and/or keep hands to him/herselfFrequently needed reminders to respect others' personal space and/or keep hands to him/herself

If this camper needed reminders to respect personal space or keep hands to themselves, how did this present? (being too close, hitting, taking others' things, etc). How often did they need to be reminded?

This camper's social interaction with peers*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

Comments about social interaction with cabinmates and peers:*

Please provide additional information on camper's social interaction or any information that you think would be helpful to caregivers, school or therapy personnel, and/or future camp staff.

This camper preferred to interact with*

peersstaffThis camper enjoyed interacting with peers and adults equally.

When given an instruction or request by staff, this camper*

complied the first time an instruction was givencomplied after the instruction was repeated several timesoften consistently refused

When staff informed them of a rule or boundary crossing, this camper*

complied the first time an instruction was givencomplied after the instruction was repeated several timesoften consistently refused

If this camper needed reminders to follow staff directions or camp rules, what did this look and sound like? (Yelling no, shutting down, continuing behavior, etc.)

Did this camper respect the boundaries of staff/camp?*

	Did not cross boundaries	Needed some reminders about boundaries	Frequently crossed this boundary.
Conversational Boundaries (Discussed inappropriate subjects, used inappropriate language.)
Behavioral Boundaries (Acted in an inappropriate manner)
Emotional Boundaries (Tried to involve themselves in personal matters, wanted to form inappropriate relationships.)
Physical Boundaries (Invaded personal space, did not keep hands and feet to selves)

This camper's social interaction with staff*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

Comments about social interaction with staff:*

Please provide additional information on camper's social interaction with staff or any information that you think would be helpful to caregivers, school or therapy personnel, and/or future camp staff.

Definitions:

Independent – Individual is able to complete the task with no assistance and little to no prompting.

Supervision – Individual is able to complete task with some prompting or reminders.

Minimal Assistance – Individual needs frequent prompting, step by step instructions, and/or some physical assistance to complete the task.

Moderate Assistance – Individual needs physical assistance to complete the task.

Total Assistance – due to physical limitations or skill deficits, the individual is unable to complete the task and it must be done for them.

Hygiene/Grooming/Health*

	Independent	Supervision	Minimal Assistance	Moderate Assistance	Total Assistance
General Toileting
Toileting after Bowel Movement
Showering Body
Washing Hair
Combing/Brushing Hair
Styling Hair (particularly if long)
Dressing While Dry
Dressing While Wet
Brushing Teeth
Mobility
Taking Medication
Washing Hands

This camper's independence in hygiene and grooming*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

Cabin Cleanup*

	Independent	Supervision	Minimal Assistance	Moderate Assistance	Total Assistance	Not Applicable
Making bed
Picking up area
Putting dirty clothes in bin
Putting away clean laundry
Sweeping
Cleaning Mirrors
Cleaning Sinks/Showers
Cleaning Toilets

This camper's independence in helping with cabin cleanup*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

Manners and Table Etiquette*

	Frequently	Occasionally	Seldom	Never	Not Applicable
Used napkin appropriately
Used utensils appropriately
Poured beverages independently
Dished up Food independently
Used good manners
Had appropriate table conversations
Waited patiently before and after meals
Willingly tried new foods
Drank water without prompting (Hydration)
Ate a variety of foods from all food groups

This camper's independence at meals, table etiquette and manners*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

Comments about activities of daily living:*

Please provide additional information on camper's hygiene and grooming, help in the cabin, and/or table manners or any information that you think would be helpful to caregivers, school or therapy personnel, and/or future camp staff.

What type of activities did this camper enjoy during free time? (Check all that apply.)*

During unstructured free time, this camper*

Was able to fill the free time on their own/independently found activities they enjoyed.Was able to choose an activity if given options and could fill the free time once engaged.Needed help finding and engaging in an appropriate free time activity.

During unstructured free time, this camper*

Would often initiate group activities and/or invite others to join activities.Would often join in group activities if invited by others.Preferred to do things alone.

During small group activities/classes, this camper*

Actively participated without promptingNeeded encouragement and prompting to participateRefused to participate

If a camper refused to participate or needed encouragement or prompting, what did this look/sound like? (Yelling, shut down, refusing to move, etc.) How frequently did this occur? (Every class, multiple times a day, every day, etc.)

During small group activities/classes, this camper*

Seemed to understand instructions, directions, and rules of games and activities with little to no prompting.Understood instructions, directions, and rules of games and activities with a few reminders or prompting.Did not understand instructions, directions, and rules of games and activities.

During small group activities/classes, this camper*

Would usually comply with instructions, directions, and rules of games and activities with little to no prompting.Needed some reminders or prompting to comply with instructions, directions, and rules of games and activities.Frequently would not comply with instructions, directions, and rules of games and activities.

During small group activities, this camper

Had a good attitude/displayed good sportsmanship/encouraged othersNeeded some reminders or prompting to have a good attitude/display good sportsmanship/encourage othersOften did not have a good attitude/display good sportsmanship/encourage others

If a camper did not have a good attitude/display good sportsmanship/encourage others what did that look/sound like? How did the camper handle winning and losing or something not going their way?

During large group activities/evening activities, this camper*

Actively participated without promptingNeeded encouragement and prompting to participateRefused to participate

If a camper refused to participate or needed encouragement or prompting, what did this look/sound like? (Yelling, shut down, refusing to move, etc.) How frequently did this occur? (Every class, multiple times a day, every day, etc.)

During large group activities/evening activities, this camper*

Seemed to understand instructions, directions, and rules of games and activities with little to no prompting.Understood instructions, directions, and rules of games and activities with a few reminders or prompting.Did not understand instructions, directions, and rules of games and activities.

During large group activities/evening activities, this camper*

Would usually comply with instructions, directions, and rules of games and activities with little to no prompting.Needed some reminders or prompting to comply with instructions, directions, and rules of games and activities.Frequently would not comply with instructions, directions, and rules of games and activities.

During large group activities, this camper

Had a good attitude/displayed good sportsmanship/encouraged othersNeeded some reminders or prompting to have a good attitude/display good sportsmanship/encourage othersOften did not have a good attitude/display good sportsmanship/encourage others

If a camper did not have a good attitude/display good sportsmanship/encourage others what did that look/sound like? How did the camper handle winning and losing or something not going their way?

This camper's participation/ attitude/ behavior during unstructured free time*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

This camper's participation/ attitude/ behavior during small group activities/classes*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

This camper's participation/ attitude/ behavior during large group activities/evening activities*

improved during the camp session.regressed during the camp session.stayed the same during the camp session.

Comments about free time/small group activities/large group activities:*

Please provide additional information on camper's participation/attitude/behavior during free time, small group activities, large group activities or any information that you think would be helpful to caregivers, school or therapy personnel, and/or future camp staff.

Token Economy System*

This camper seemed to understand the token economy systemThis camper needed reminders about how to earn tokens or what they were used for.This camper did not understand the token economy system

Response to the Token Economy System*

This camper responded well to tokens and wanted to earn tokens/was impacted by not receiving tokensThis camper understood tokens but granting or receiving tokens did not seem to affect campers behaviorCampers did not care about tokens.

The most effective reinforcer(s) with this camper seemed to be:*

Camper Abided by Camp Grassick Behavior Policy*

	Always abided by behavior policy	Usually abided by behavior policy	Sometimes abided by behavior policy	Rarely abided by behavior policy	Camper was disciplined or sent home due to non compliance
Camper was Safe (no fighting, hitting, kicking, inappropriate sexual conduct, weapons, drugs, alcohol, etc)
Camper was Responsible (stealing, damaging property, not participating in camp or cabin cleanup)
Camper was Respectful (disrespect, refusal to follow rules, threatening, bullying, inappropriate or unkind language)
Camper Tried (refused to go to classes, therapies, meals, refused attempts at non preferred things)

What was this camper's baseline behavior while at camp? (What did they look and sound like when they were HRE - happy, relaxed and engaged with their environment?) What percentage of the day were they at baseline?

Did this camper exhibit any significant or frequent periods of dysregulation?*

NoYes

What set off the behavior or dysregulation?

What did the behavior look or sound like?

How often did the camper exhibit these behaviors?

How long did each behavior typically last?

Is there anything that deescalated the behavior? What calmed them down?

Is there any strategies or interventions that you felt worked well with this camper that you would recommend to caregivers, teachers or therapists?

Are there any additional comments you would like to add about this camper's behavior or behavior intervention?

Would you recommend that we accept this camper to this session next year?*

YesNo

Do you feel that this camper would be better suited to a different camp session next year?

Counselor's Report

Adjustment to Living Away from Home and Adaptability to Camp Life

Social Interaction with Peers:

Social Interaction with Staff:

Activities of Daily Living While at Camp Grassick

Activities: Free Time, Small Group, and Large Group

Response to Behavior Intervention