CLIENT DOCUMENTATION DRAFT
Client Documentation Final Draft
Jenny Kougias
University of St. Francis
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CLIENT DOCUMENTATION DRAFT
Setting and Program Description:
The setting of the therapeutic recreation services are at SEASPAR (South East
Association for Special Parks and Recreation). They have multiple recreation therapists with
CTRS certifications as well as inclusion aides and program assistants. They also have professionals with CPRP certifications that can offer additional assistance and knowledge. The special recreation association serves Brookfield, Claredon Hills, Darien, Downers Grove,
LaGrange, Lisle, Western Springs, Westmont and Woodridge.
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There are a variety of programs and services offered at SEASPAR. The facility offers programs in a variety of interests for all ages. The facility serves children, teenagers, young adults, adults and also provides nursing home outreach. Any age group that lives in the area that
SEASPAR serves is welcome to participate in recreational programs. A brochure is distributed three times a year for the fall, spring, and summer season. The facility has programs that run all three seasons and others who are only offered a certain season. Some examples of programs that are offered every season are the EAGLES adult day program, and the social club program.
Examples of programs that are not offered all year round are summer swimming programs and winter sports. Some of the programs SEASPAR offers are cooking programs, animal assisted therapy, special events, social programs as well as sports programs. The facility is also involved in Special Olympics and actively participates in the program. SEASPAR is always open to new program ideas from interns, suggestions from parents/ the community as well as others.
SEASPAR is a reputable facility that offers many services to its clients. They serve many communities and continue outreach to other neighboring towns to expand their services. Any client can find that SEASPAR can fulfill their needs due to the variety of services that
SEASPAR provides.

CLIENT DOCUMENTATION DRAFT
Client History and Demographics:
Age: 25
Gender: Male
Ethnicity/Racial Background: White/Caucasian
Diagnostic Information: Down syndrome, aphasia, mild IBS irritable bowel syndrome), loose neck, anxiety and social withdrawal.
Social History : Lives with parents who are financially stable. Client works at a store trying to gain some independence.
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Reasons for referral to TR : Needs to improve on social skills and speech skills due to aphasia.
Parents of client and client desire more participation in social leisure programs in order to gain more control over social skills and speech difficulties.
Assessment Instruments:
1.
Leisure Diagnostic Battery
The leisure diagnostic battery would be appropriate for the client because the client needs to be assessed in leisure functioning. The client’s social skills need to be improved in the social area, and this assessment will aid in the understanding of what the client needs to improve on in detail.
2.
Functional Assessment of Characteristics for Therapeutic Recreation
This assessment determines the client’s needs through their behaviors and functional skills. The client lacks social skills and wants to improve them. The instrument will determine what needs to be done in order to improve the client’s social skills.
3.
Leisure Interest Measure
This assessment assesses the client in interests in all 8 domains. Social programs are appropriate for this program but this assessment will determine what types of social

CLIENT DOCUMENTATION DRAFT programs will be beneficial to him. The social programs are needed to not only promotes social skills, but for the client to explore their interests; also to discover new interests.
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Assessment Report:
The assessment tool that was used was the leisure diagnostic battery which assesses the client by using 8 components. These 8 components are called perceived freedom, perceived leisure competence, perceived leisure control, leisure needs, depth of involvement in leisure, playfulness, barriers to leisure experience, and leisure preferences. This assessment provided clear and concise results on the client’s ability to socialize with others using the 8 components.
The assessment results showed that the client has a strong interest in pursuing social programs related to recreation, but is nervous to do so because of his mild aphasia. During the assessment the client was eager to answer questions but did get nervous if he could not say words clearly.
His aphasia was determined by the assessment to be a leisure barrier. The client does have leisure confidence, playfulness and leisure preferences, but could show some improvement in depth of involvement in leisure and leisure control.
Strengths:
Client showed good outcome in the following sections:
Perceived freedom, leisure need, playfulness and leisure preferences.
Client also shows strengths in his attitudes towards leisure. He has a desire to participate and enjoys leisure.
Physical domain: Physical ability is strong and client is able to complete most physical activities on his own such as walking, toileting, etc. He is fully functional in his arms and legs.
Social domain: Client is eager and willing to improve his social skills, shows interest in social programs.
Enjoys socializing and is willing to work on his needs in this area.

CLIENT DOCUMENTATION DRAFT 5
Cognitive domain: Client shows strengths in most cognitive abilities such as managing money, managing time and is self-motivated and able to focus on tasks.
Emotional/behavioral domain: Client has manners, respects others and does not act out on his emotions if he becomes frustrated. Client has a good sense of control over his emotions and behaviors. If client does get frustrated he knows how to act out on it appropriately.
Leisure domain : Client has interest in leisure and is open and willing to try new leisure activities to improve some areas that might need to be worked on.
Needs:
Client needs to improve on overall social skills but his aphasia was considered a barrier to leisure experience. Depth of involvement in leisure can use improvement. Client will increase the depth of involvement if he can work on improving social skills. Client might have more interest in participating in social groups in more depth if he is more comfortable speaking with his fears despite aphasia.
Physical domain: Client does experience loose neck because of Down-syndrome which limits him from certain physical activity.
Social domain: Client has desire to participate in social activities but has problems with anxiety due to his aphasia which in turn affects his social interaction with others.
Cognitive domain : Client needs assistance with initiating conversation.
Emotional/behavioral domain: Client often gets nervous and stumbles on words when he is talking to other people. He shows emotion when speech disturbances happen and his behaviors change. He will be embarrassed which causes him to become shy.

CLIENT DOCUMENTATION DRAFT
Leisure domain: Clients mild speech impairment is a barrier for him to be able to enjoy social activities to their full potential.
Treatment Plan:
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Client Treatment Goals:
1.
Client will improve basic social skills by participating in an adult day program.

Client will actively engage in conversation when the program collaborates with another SRA with a minimum of two peers from the other SRA.

Client will participate in adult day program for a minimum of 5 days per week for the entire duration of the program.

Client will demonstrate social techniques by participating in at least one field trip with the adult day program for one full day of the programs duration.
2.
Client will actively socialize and interact in the “social club” program at least once per week as observed and recorded by CTRS.

Client will actively participate in activities in the “social club” program at least once a week for a minimum of 3 hour duration.
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Client will interact with at least two different peers during an unfamiliar activity in social club as recorded by CTRS.
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Client will greet the therapist or staff members that are with him each week as clearly and concisely as possible with a minimum of two employees each week.
Action Plan:

Enroll client in the EAGLES day program M-F 8:00am-4:00 pm.

CLIENT DOCUMENTATION DRAFT
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Enroll client in “Social Club 5” that meets every Friday for a different activity each week from 6pm-9pm.
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Therapist’s signature:
Jenny Kougias, signed 4/14/15
Progress Note:
Problem: Speech due to aphasia
S: Client says “I sometimes feel uncomfortable talking in social situations”
O: Client attempts to talk to peers but often shy’s away because he is afraid others will not hear what he is trying to say.
A: Clients continued avoidance of social situations does not help speech improve. Client needs further motivation to be able to initiate conversation with peers during social programs.
P:
1.
Continue to observe client in both the EAGLES program and the “Social Club 5” program.
2.
Schedule a 1:1 client/ therapist interaction to discuss concerns with socializing with peers.
3.
Consider enrolling client in a leisure education program for client to have slight improvement in social skills before going back to the social programs.
I: Observe and test client’s willingness to initiate conversation with peers in the social programs that he is currently enrolled in.
E: Client expressed concerns in 1:1 interaction and over time speech has gotten slightly more clear; but client still needs improvement.
R: Client expresses that he feels uncomfortable around peers due to his poor speech and aphasia.
Recommendations include more interaction in the leisure education program. Leisure education program can increase from 1x per week to 2x per week.
Therapist’s signature: Jenny Kougias, signed 4/14/15