Special Needs Assessment

This assessment helps us get to know you/your child/adult better. We want everyone to be successful in all of our programs. The more information we have, the better chance of success. All information you provide is confidential and will be shared with only the staff involved in the program. Please contact Eileen at ecicchese@groton-ct.gov or 860-536-5691 to discuss your or your child's needs. If something doesn't not apply, put N/A not applicable.

We assess all participants to determine the staff ratio that they will be successful. Is it your opinion that the participant needs a 1:1 staff with them in the program to be successful ?* Yes No

Please check if the participant uses any of the following devices. communication board hearing aids augmentative & alternative Communication (AAC) weighted vest rifton chair pecs board glasses

List any suggestions for additional assistance you think the participant might require to be successfully included in a recreation setting.

Unless otherwise indicated, I grant permission to Groton Parks and Recreation to contact the school, teachers assistant, teacher, social workers, therapist or physician for the purpose of gathering or releasing information regarding this participant. The information will be used to provide the most effective plan for providing recreation services and proper placement in inclusion. All information will be kept confidential.

Special Needs Assessment

Recreation Assessment

Medical Information

Swimming

Mobility

Behavior/Personality

Social

Cognitive

Personal Care

Safety

Authorization to Contact and Release of Information

Government

Departments

Residents

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