(Sample- name & content are fictional)

NAME:	  John Doe                               Hospital #:
AGE:      21					 CHILDREN:  None
SEX:	  Male					 EMPLOYMENT:  Sub Shop
MARITAL STATUS:	Single		 HOMETOWN:  Johnsburg


REASON FOR REFERRAL:  
	To assess leisure interests and to explore alternative 
	activities to alcohol misuse.

MEDICATION AND IMPLICATIONS FOR RECREATION PARTICIPATION:  
	Haldol and Tegretol-  pt should be warned against participation 
	in activities that require alertness and good psychomotor 
	coordination until CNS response to drug is determined.

ASSESSMENTS
	Assessments used to determine John’s leisure interests, leisure 
	functioning level, and leisure participation levels included:
		Perceived Freedom in Leisure Scale, Short Version
		Barriers to Leisure Involvement Scale
		Leisure Interest Survey
		Interview

LEISURE INTERESTS
	Soccer, driving around in a car, softball, basketball ("just 
	shooting around with friends"), billiards, beer pong (drinking 
	game), listening to music, dancing, attend sporting events, take 
	things apart (e.g., electronics "when in the mood"), writing, 
	passing a football, cooking, telling jokes.  
	
	John has a high degree of interest in passive-oriented activities 
	such as watching sporting events on TV, listening to music, and 
	daydreaming/thinking.  He also prefers social activities such as 
	going to parties, doing activities with friends and belonging to 
	groups such as his fraternity.  
	
	Some of his preferred interests are associated with drinking.  
	For example, after playing basketball, he and his friends would 
	drink beer.  Shooting pool, drinking games and dancing are 
	associated with his drinking.

LEISURE PURSUITS PRIOR TO  ADMISSION
	John has noted that drinking has consumed much of his free-time.  
	On work days, he goes to work at 11am to 4 or 9pm.  Returns from 
	work feeling tired but having the urge to socialize and drink 
	beer.  He notes that he rarely drinks alone.  On non-work days, 
	he wants to do something productive and usually ends up drinking 
	beer.  He noted that getting away in his car helped.  This 
	usually kept him from drinking (although patient did note that 
	he lost his drivers license due to DUI).  Most non-work days, 
	friends usually stop by with a case of beer or he goes to their 
	residences with beer. 
	
GENERAL APPEARANCE
	John was dressed casually and was neat.  Affect bright.  
	Engaging pleasantly with CTRS during interview.  

PHYSICAL DISABILITIES
	None indicated by patient

FUNDING LEVEL
	Patient has been employed in a local sub shop and reports 
	that when he leaves the hospital his job is waiting for him.  
	He endorses (from Barriers to Leisure Involvement Scale) that 
	money, or the lack of it, is not a barrier to his leisure 
	involvement.

MOTIVATION LEVEL
	Patient has indicated throughout the interview his need to stop 
	drinking because "my medicine and beer don’t mix well together."  
	He expressed, however, that he didn’t think drinking was a real 
	problem and that he wouldn’t want to go to AA meetings if someone 
	suggests he go.  John was insightful in regards to the effect 
	his drinking had on his leisure involvement and how he stopped 
	doing many of his preferred activities.  

	John views himself as generally being independent in his pursuit 
	of leisure activities.  He sees himself as being competent in 
	many leisure activities and often gets excited with doing 
	activities.  He notes that his self-esteem is "OK" and has 
	improved since graduation from high school and from being in a 
	fraternity in college.  His drinking activities, however, has 
	curtailed his leisure involvement. 
 
	When asked what motivates him to play basketball (his favorite 
	activity), John noted "the good feeling from playing, exercise, 
	and knowing that I did my best."  When asked what motivates him 
	to drink beer, he said, "I don’t know... I just drink."

SOCIALIZATION LEVEL
	John prefers the company of others.  He sees himself as a 
	"class clown" and enjoys telling jokes and "ragging on others."  
	During this interview, he displayed to ability to be quite an 
	engaging conversationalist.  He noted that he just recently 
	broke up with a girl and was despondent for a while but has 
	gotten over that.  He wanted to meet girls and believed that 
	the only place he could meet a girl was at a bar.  Other than 
	a bar, he was not able to name a single location or event in 
	which he could meet girls.

GOALS
	Personal goals suggested by John included coaching a youth 
	basketball team sometime in the future, using the city bus line 
	not just to go to work but to go to recreation events and to 
	find a girl to be with.