Horticultural Therapy Initial Evaluation (Clinical)

Patient: [Full name] | DOB: [MM/DD/YYYY] | MRN: [MRN]

Date/Time: [Evaluation date]; [Start time–Stop time / Total duration]

Location: [Unit / Clinic / Garden / Greenhouse]

Discipline: Horticultural Therapy

Clinician: [Name, credentials]

Referral Source: [Referring provider/service]; Referral Date: [MM/DD/YYYY]

Reason for Referral / Evaluation Focus

• [Referral reason and clinical question(s) to be answered] (Include verbatim referral language if useful)
• [Patient-stated goals] (Use direct quotes when possible)
• [Specific participation or safety focus areas if requested] (e.g., tool safety risk, group readiness, behavioral activation, fine motor function, coping skills)

Diagnoses / Precautions / Restrictions

(List only confirmed diagnoses/conditions from referral or chart relevant to HT participation. Do not infer diagnoses; document observed limitations separately in Baseline Function.)

• Relevant Diagnoses/Conditions: [Diagnoses from chart/referral, or "None stated"]
• Precautions: [Medical, behavioral, and environmental precautions] (e.g., weight-bearing status, seizure risk, oxygen needs, bleeding risk, immunocompromised status, sensory limitations, elopement risk, aggression, self-harm history, heat/cold intolerance, pollen/latex allergy)
• Restrictions: [Activity, tool, or environment restrictions] (e.g., no sharps, no soil/compost access, no outdoor garden)
• Contraindications: [Absolute contraindications, or "None identified per patient report and chart review"]

Information Sources

• [Patient interview quality and limitations] (e.g., alertness, communication barriers)
• [Caregiver/family input] (Name/relationship if applicable)
• [Staff input] (Discipline/unit if applicable)
• [Chart/record review] (Key documents reviewed)
• [Interpreter used] (Language, if applicable)
• [Assistive supports present] (e.g., hearing aids, glasses, mobility device)

Relevant History / Context

(Include only information that affects participation, safety, goals, or prognosis.)

• [Medical/psychiatric history relevant to activity tolerance or safety]
• [Living situation and anticipated discharge environment]
• [Meaningful roles, routines, responsibilities informing HT goals]
• [Substance use if directly impacting tool safety or participation] (Include only if relevant)
• [Trauma-informed considerations for safe engagement] (High-level only; omit sensitive details not affecting the plan)

Baseline Function

(Document observable, measurable function relevant to gardening tasks. Use quantitative anchors and assistance/cueing levels. Attribute information to source; use "as evidenced by" to describe behaviors. If standardized measures used, report tool name, score, and brief interpretation. If testing not possible, state reason and alternative observation.)

Mobility/Balance

• [Transfers and gait] (Assistance level, device used, distance/time)
• [Endurance/activity tolerance] (Minutes tolerated, rest break frequency)
• [Uneven surfaces/terrain tolerance] (Raised beds, gravel, grass)
• [Fall risk indicators] (Loss of balance episodes, guarding needs, recent falls)

Upper Extremity

• [Reach, grasp, pinch strength, bilateral coordination] (As evidenced by tool handling, pot carrying, watering can control)
• [Fine motor control] (Seed handling, transplanting speed/accuracy, error count)
• [ROM limits, tremor, or pain impacting use]

Sensory

• [Vision for detail work and hazard detection] (Corrective lenses, observed misses/errors)
• [Tactile tolerance for soil/textures] (Glove needs)
• [Smell sensitivity or respiratory considerations]
• [Hearing for group instruction] (Hearing aids, volume/cueing needs)

Cognition/Executive Function

• [Attention and distractibility] (Number of redirections needed)
• [Sequencing and problem-solving] (Multi-step task performance, error count, cueing type)
• [Safety awareness, impulsivity, judgment] (Tool handling decisions, boundary testing)
• [Ability to follow multi-step directions] (Accuracy, latency, cueing level)

Communication

• [Expressing needs and preferences] (Clarity, assistive communication needs)
• [Comprehension and following directions] (Verbal/visual/demo cueing effectiveness)
• [Social pragmatics and group interaction] (Turn-taking, topic maintenance)

Pain/Fatigue

• [Pain location, intensity, and triggers] (Scale rating; triggers such as kneeling, gripping)
• [Fatigue barriers] (Onset time, recovery time)

Psychosocial Presentation

• [Observed affect, mood, and engagement] (As evidenced by participation and persistence)
• [Frustration tolerance and behavioral regulation] (Response to errors, need for breaks)
• [Response to redirection and cueing] (Verbal/visual/gestural; effectiveness)
• [Safety behaviors] (Rule following, help-seeking, boundary awareness)

Standardized Measures

• [Tool name and version]: [Score]; [Brief interpretation relevant to HT]

(If not administered, state reason and alternate observation method used.)

Horticultural Profile

• [Prior gardening experience and comfort level]
• [Culturally meaningful plants or foods and preferences] (Include quotes when helpful)
• [Preferred activities] (e.g., propagation, watering, arranging, vegetables, indoor plants)
• [Current skill baseline with tools and task sequencing] (Steps completed, accuracy observed)
• [Identified barriers and adaptive equipment needs] (e.g., raised beds, ergonomic tools, seating)
• [Carryover potential] (Home access to plants/tools, caregiver support, safe space)

HT Risk Screen & Safety Plan

(Document risks and mitigation strategies specific to horticultural therapy. If a domain cannot be assessed, state reason and apply conservative default restrictions.)

• Tool Safety: Risk factors: [List]. Tools planned: [Sharps / pruners / trowels / other]. Mitigation: [Supervision level, tool check-in/out procedures, sharps alternatives, storage rules].
• Allergen/Irritant/Exposure Risk: Risks: [Plant/pollen allergies, latex allergy, contact dermatitis, immunocompromised status, open wounds]. Controls: [Glove type, mask if indicated, soil handling precautions, compost restrictions, hand hygiene protocol, indoor alternatives].
• Environmental/Fall Risk: Risks: [Uneven ground, wet surfaces, hoses, steps, heat/cold exposure]. Controls: [Seated tasks, raised beds, mobility device access, hydration/rest breaks, footwear requirements, climate modifications].
• Behavioral Risk: Risks: [Elopement risk, aggression triggers, boundary violations]. Controls: [Effective de-escalation strategies, staffing level, proximity requirements, visual rules/supports].

Screening Summary: [Risks identified as documented above / Screening completed with no significant risks identified]

(If unable to assess any domain, document reason and conservative default restrictions applied.)

Assessment

[Clinical synthesis of evaluation findings] (Address what limits participation, what supports success, and the most safety-critical issues in 5–8 sentences. Include a skilled need statement explaining why HT requires clinical reasoning—grading, adapting, safety management, therapeutic use of activity. State prognosis and rehabilitation potential with rationale, conditioned on adherence and supports.)

Problem List

(List in priority order with safety-critical problems first. Each problem should be observable, actionable, and tied to HT participation.)

1. [Problem] — Evidence: [Baseline metric/behavior]; Impact: [Effect on participation or safety]
2. [Problem] — Evidence: [Baseline metric/behavior]; Impact: [Effect on participation or safety]
3. [Problem] — Evidence: [Baseline metric/behavior]; Impact: [Effect on participation or safety]

Goals

(Use measurable, behaviorally anchored goals with timeframe, condition, behavior, and criteria. Reference baseline where relevant.)

Long-Term Goal(s) [Timeframe]:

• [Condition]: Patient will [functional HT participation outcome] with [assistance/cueing level] achieving [safety/accuracy/duration/frequency criteria] to support [participation goal or role].

Short-Term Objectives [Timeframe]:

• Tool safety: Patient will [follow tool safety rules] under [supervision level] in [frequency/percentage] of opportunities with [cueing level] and zero safety incidents.
• Task completion: Patient will complete [number]-step horticultural task with [cueing level], [accuracy criteria], within [time frame].
• Participation tolerance: Patient will engage in HT activities for [duration] with [break schedule] while maintaining [exertion/pain thresholds] and safe technique.
• Self-regulation: Patient will utilize [coping strategy] during HT in [frequency/percentage] of opportunities with [cueing level], as evidenced by [observable behaviors].
• Functional skills: Patient will [improve specific skill] to [quantified target] to support [specific HT task].
• Social interaction: Patient will [target social behavior] in [frequency/percentage] of opportunities with [cueing level] while adhering to group norms. (Include for group HT)
• Carryover planning: Patient/caregiver will identify [home/community resources] and demonstrate safe setup for [home HT activity] with [independence level].

Plan of Care

• Frequency/Duration: [Sessions per week] for [number of weeks or episode description]
• Intervention Approach: [Individual / Group]; [Indoor / Outdoor]; [Graded progression plan]; [Adaptive equipment and cueing strategies]
• Risk Controls: [Supervision level, tool restrictions/alternatives, PPE, fall precautions, exposure controls]
• Interdisciplinary Coordination: [Disciplines and specific coordination needs]
• Education Provided: [Topics covered: safety rules, tool handling, hygiene protocols, environmental hazards]; Patient understanding: [Verbalized / Demonstrated via teach-back / Return demonstration]
• Home/Carryover Recommendations: [Home setup, caregiver training, community resources, supplies]
• Reassessment Plan: [Intervals and criteria for reassessment or progression]
• Discharge Planning: [Anticipated discharge criteria, timeline, referrals for ongoing participation]

Signature

Clinician Signature: [Signature with credentials, date/time]

(Throughout the note, clearly attribute information to its source: patient report, caregiver/staff report, chart review, or therapist observation. Describe behaviors with "as evidenced by" language rather than interpretive labels. If information is missing or not assessed, explicitly state this with the reason rather than leaving sections blank. Omit sections or subsections that are not applicable, but do not omit the HT Risk Screen & Safety Plan section—if no risks are identified, document that screening was completed with no risks identified.)