SECTION 29: RECREATION PROGRAM, BUREAU OF SERVICES TO THE BLIND AND VISUALLY IMPAIRED
Procedure for Recreation Program
A. The Rehabilitation Counselor completes the Recreation Program Referral Form. The referral form is accompanied by the Intake Summary, any Progress Review Notes with pertinent information, and medical and psychological information documenting functional limitations. The Referral Form may be mailed electronically to the Rehabilitation Technician with the hard copy information delivered separately.
B. Upon receipt of the referral, the Recreation Specialist schedules an initial appointment with the participant in a timely manner.
C. Following that appointment, the Recreation Services Evaluation Summary/Report is completed and a copy is sent to the Rehabilitation Counselor in a timely manner.
D. An Individualized Written Program of Instruction is completed and signed by Recreation Specialist and participant and a copy is sent to the Rehabilitation Counselor in a timely manner. The Specialist will ensure that participation in the recreation program is commensurate with the medical status and limitations of the participant. The Specialist will obtain physician approval for participation as necessary. The Specialist will ensure that each participant is properly trained on the use of any recreation program equipment. The Specialist will ensure that each participant is properly supervised during program activities. The Specialist will ensure that the participant is covered by Worker’s Compensation during participation in the program.
E. The Recreation Specialist completes a Recreation Monthly Report on all participants, which outlines the status of the program instruction and sends a copy to the Rehabilitation Counselor.
F. The Recreation Specialist will hold staffings of program participants upon request or when there is an identified need to do so.
G. A Recreation Program Case Closure Form is completed at the time of each case closure and a copy is sent to the Rehabilitation Counselor.
H. The Recreation Specialist will maintain a recreation file form on each participant. All forms used in the program will be filed in the case file as follows:
Section 1: Referral form and information
Section 2: Recreation Services Evaluation Summary Report
Individualized Written Program of Instruction
Recreation Program Case Closure Form
Section 3: Recreational Monthly Report – in date order with the most current on top.
Staffing PRN’s
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 131
Bureau of Services to the Blind & Visually Impaired
Recreation Program Referral Form
Participant Name: Case Number:Address:
Phone Number:
Work/Alternative Phone #:
Age:
Please describe in detail impairment(s) including LIMITATIONS, PRECAUTIONS and/or MEDICATIONS:
1. Disability (Including Primary and Secondary):
2. Adaptive Equipment Needs/Used:
3. Status of Independent Travel: Independent Requires Assistance (please comment if requires assistance):
RECREATION SERVICES NEEDED:
Work Hardening General Physical Fitness & Recreation Training (Physicians note required)
(Can list specific activities: including Biking/Skiing/Weights/Gym, etc.)
Fitness Evaluation Fitness Education Recreation Evaluation
(Includes info. on community Rec. resources)
Leisure Counseling Group Activities
PURPOSE OF REFERRAL AND GOAL:
Rehabilitation Counselor Signature: _ Date: ______BUREAU OF SERVICES TO THE BLIND AND VISUALLY IMPAIRED
RECREATION SERVICES
EVALUATION SUMMARY/REPORT
DATE:
EVALUATION SUMMARY BY:
PARTICIPANT NAME: CASE NUMBER:
REFERRED BY:
REASON FOR REFERRAL (Explain in Detail):
Updated Information Since Intake:
Disability Status: STABLE PROGRESSIVE
Current Recreational Experience/Social History/Activity:
EVALUATION OF RECREATION NEEDS:
Observation:
Needs:
Page 1 of 2
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 133
EVALUATION SUMMARY/REPORT CONTINUED
PARTICIPANT NAME: CASE NUMBER:
Action Taken:
Evaluation Summary:
Recommendations:
Evaluation Ending Date: Moved to Training:
Projected Timeline to Reach Recreation Goals:
______
Recreation Specialist Date
Page 2 of 2
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 134
Recreation Program Initial Assessment
Participant: Age: Weight:
Precautions:
Pain 1 to 10:
Lives: Alone Spouse Other Marital Status: S M W D
Dominant Hand: R or L Children: Pets:
Sight: Normal Glasses/Contacts Visually Impaired/Blind
Hearing: Normal Hearing Aid Hearing Impaired
Transportation:
LEISURE ACTIVITIES:
Games Exercise Hobbies
___Cards ___ Gym ___Cooking
___Board Games ___Aerobics ___Collecting
___Bingo ___Walking ___Photography
___Puzzles ___Dancing ___Traveling
___Crosswords/ Word Search ___Swimming ___Other
___Other ___Other
Entertainment Sports Social
___TV ___Watch on TV ___Friends
___News/Newspaper ___Golf ___Special Events
___Movies ___Bowling ___Groups
___Theatre ___Pool ___Volunteer
___Music ___Ski ___Other
___Concerts ___Other
___Reading
___Computer
___Other
Arts & Crafts Outdoor Activities Creative Expression
___Woodworking ___Gardening ___Singing
___Leatherworking ___Hunting/Fishing ___Poetry
___Crochet/Knit/Sewing ___Water Sports ___Writing
___Pottery/Ceramics ___Camping ___Journal/Diary
___Other ___Hiking ___Painting
___Boating/Sailing ___Musical Instr.
___Bicycling ___Other
___Picnics
___Other
Page 1 of 2
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 135
Recreation Program Initial Assessment Continued
Participant:
BARRIERS TO LEISURE:
___Low Energy Level ___Lack of Motivation ___Poor Time Mgmt
___Decision Making ___Lack of Finances ___Boredom
___Low Self-Esteem ___Physical Condition ___Work
___Lack of Independence ___Medications ___Other
___Stress ___Conflict w/Peers
Participant Goals:
______
Strengths: ______
Limitations: ____________
PARTICIPANT LEISURE CHART:
Page 2 of 2
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 136
Bureau of Services to the Blind & Visually Impaired
Recreation Program
INDIVIDUALIZED WRITTEN PROGRAM OF INSTRUCTION
Participant Name: Case Number:
Rehabilitation Counselor: BSBVI BVR
Recreational Goal:
Services:
Start Date:
Projected Completion Date:
Estimated Cost:
Recreational Goal:
Services:
Start Date:
Projected Completion Date:
Estimated Cost:
I understand full payment for services by the Rehabilitation Division may be affected by the amount of my income; other resources are available to me and the availability of agency funds. I understand paid services can only be obtained after they are included in the Written Program of Instruction, and a prior specific written authorization has been completed by my recreational counselor.
I agree with this Written Program of Instruction as written and have participated in the planning by making the following informed choices:
Participant Signature DATE
Recreation Specialist DATE
PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 137
Bureau of Services to the Blind & Visually Impaired
Recreation Monthly Report
Participant Name: Case Number:Rehabilitation Counselor: Date:
Assessment of Participant Progress:
Recommendations:
Anticipated Time Needed to Reach Recreation Goal(s):
Recreation Specialist Signature: Date:PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 138
Bureau of Services to the Blind & Visually Impaired
Recreation Program Case Closure
Participant Name: Case Number:Rehabilitation Counselor: Date:
Referral Date Closure Date:
Closure Summary:
Recreation Goal(s): Met Not Met (Explanation):
Recreation Specialist Signature: Date:PARTICIPANT SERVICES POLICY AND PROCEDURES MANUAL
Bureaus of Vocational Rehabilitation & Services to the Blind and Visually Impaired
Revised: 2006
Page 139