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Professional Information Sharing Form
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Hanover County Parks and Recreation
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.
Child Name (First Name and first initial of last name): i.e. John S.
Teacher and School:
Please check all appropriate statements that best describe the characteristics of the above participant:
Actively engages in activities
Hesitant when introduced to activities
Prefers to observe, stay on periphery
Generally refuses to participate
Does not respond often to verbal questions
Needs time to respond to verbal questions
Responds appropriately to verbal questions
Persists on own until task is complete
Needs some encouragement to complete tasks
Needs 1 on 1 assistance to complete tasks
Unable to finish most tasks even with assistance/encouragement
Relationship to Authority
Openly defiant to authority
Occasionally questions authority
Accepts and works well with an authority figure
Clings to authority figure - prefers staff to peers
Works cooperatively with others
Does tasks independently while others are present, interaction with others is limited
Needs prompting to work with peers
Withdraws, isolates self from groups or others
Environment for Participation
1 on 1 (staff assistance in self-contained setting)
1 on 4 (staff assistance in self-contained setting)
1 on 4 (staff assistance in an inclusion setting)
1 on 20 (staff assistance in an inclusion setting)
Ability to Follow Directions
Can follow simple verbal directions
Can follow multiple verbal directions
Needs occasional redirections
Requires contact redirection
Duration of attention is less than 5 minutes
Duration of attention is about 5 - 15 minutes
Duration of attention can be 15 minutes or longer
Has difficulty in large spaces (gym, cafeteria)
Has tendency to leave group in unconfined spaces (playground, open field)
Child does not typically have interfering behaviors or outbursts
Child has interfering behaviors occasionally
Child has interfering behaviors frequently
Child becomes emotional during an interfering behavior
Child can become physical and/or violent during an interfering behavior
Are there personal space/boundary issues that would be helpful to know?
Does this child need assistance with services of a personal care nature (i.e. using the bathroom, feeding, etc.)? If yes, please describe.
Please list some techniques in reinforcing positive behavior/discouraging inappropriate behavior (behavior plans) that have been successful.
Would a classroom observation of the child be permitted to help us create the best environment for child?
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
Thank you for your assistance!
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