Professional Information Sharing Form

4. Hanover County Parks and Recreation
6. Professional Information Sharing Form
   Dear Teacher:
   The family of this child has requested the assistance of a Therapeutic Recreation Aide during Parks and Recreation day camp programs.
   To help us allow the child to have the most successful experience possible, we’d like to learn a bit about what works best for the child in the classroom setting.
   Thanks for your help in completing this form.
10. Child Name (First Name and first initial of last name): i.e. John S.
11. Teacher and School:
12. Teacher E-mail:
14. Please check all appropriate statements that best describe the characteristics of the above participant:
16. Participation Style

    1. Actively engages in activities
    2. Hesitant when introduced to activities

    1. Prefers to observe, stay on periphery
    2. Generally refuses to participate
18. Comments:
20. Information Processing

    1. Does not respond often to verbal questions
    2. Needs time to respond to verbal questions

    1. Responds appropriately to verbal questions
22. Comments:
24. Independence

    1. Persists on own until task is complete
    2. Needs some encouragement to complete tasks

    1. Needs 1 on 1 assistance to complete tasks
    2. Unable to finish most tasks even with assistance/encouragement
26. Comments:
28. Relationship to Authority

    1. Openly defiant to authority
    2. Occasionally questions authority

    1. Accepts and works well with an authority figure
    2. Clings to authority figure - prefers staff to peers
30. Comments:
32. Group Skills

    1. Works cooperatively with others
    2. Does tasks independently while others are present, interaction with others is limited

    1. Needs prompting to work with peers
    2. Withdraws, isolates self from groups or others
34. Comments:
36. Environment for Participation

    1. 1 on 1 (staff assistance in self-contained setting)
    2. 1 on 4 (staff assistance in self-contained setting)

    1. 1 on 4 (staff assistance in an inclusion setting)
    2. 1 on 20 (staff assistance in an inclusion setting)
38. Comments:
40. Ability to Follow Directions

    1. Can follow simple verbal directions
    2. Can follow multiple verbal directions

    1. Needs occasional redirections
    2. Requires contact redirection
42. Comments:
44. Attention/Processing

    1. Duration of attention is less than 5 minutes
    2. Duration of attention is about 5 - 15 minutes
    3. Duration of attention can be 15 minutes or longer

    1. Has difficulty in large spaces (gym, cafeteria)
    2. Has tendency to leave group in unconfined spaces (playground, open field)
46. Comments:
48. Interfering Behaviors

    1. Child does not typically have interfering behaviors or outbursts
    2. Child has interfering behaviors occasionally
    3. Child has interfering behaviors frequently

    1. Child becomes emotional during an interfering behavior
    2. Child can become physical and/or violent during an interfering behavior
50. Comments:
52. Are there personal space/boundary issues that would be helpful to know?
54. Does this child need assistance with services of a personal care nature (i.e. using the bathroom, feeding, etc.)? If yes, please describe.
56. Please list some techniques in reinforcing positive behavior/discouraging inappropriate behavior (behavior plans) that have been successful.
58. Classroom Observation: Would a classroom observation of the child be permitted to help us create the best environment for child?
60. If you have any additional information that would be helpful as we work to develop an Inclusion Plan for this child, please feel free to contact Hanover County Parks and Recreation at 804-365-7150 or via email at [email protected] Thank you for your assistance!
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field