Initial Evaluation Note (Animal-Assisted Therapy)

Date/Time: [Date and time of evaluation]

Location/Setting: [inpatient / outpatient / school / home / community / other]

Clinician: [Name, credentials, discipline]

Note Type: Initial Evaluation — Animal-Assisted Therapy

Visit Context: [initial evaluation / transfer of care / re-evaluation]

Participants Present: [Patient, caregiver/guardian, interpreter, other staff as applicable]

AAT Team Present: [Handler role/title, animal species, animal name/identifier] (If no animal present, state: "Evaluation completed without animal present.")

Reason for Referral

[Referral source and reason; requested outcomes; primary symptoms and functional limitations; relevant diagnoses if known] (1–3 sentences.)

Consent and Participation Preferences

• Treatment Consent: [Yes / No] (Include guardian consent when applicable; document assent for pediatrics or dependent adults.)
• Consent for Animal Interaction: [Yes / No / Deferred] (Document preferences and boundaries: [touching / proximity only / no touch]; [on-bed / off-bed].)
• Cultural/Religious/Personal Considerations: [Relevant beliefs, preferences, or boundaries regarding animals]
• Stop Criteria Reviewed: [Yes / No] (Patient may stop at any time; animal may be removed if stressed; staff may stop for safety reasons.)

History and Baseline Context

Chief Concern: [Patient-stated concern] (Use direct quotes when helpful.)

History of Present Illness: [Symptom profile including onset, duration, triggers, relieving factors; functional impact on ADLs, mobility, school/work, social participation; prior treatments and response including prior AAT exposure; patient-stated goals and motivation]

• Relevant Medical/Behavioral History: [Respiratory disease/asthma; immune status; skin integrity; seizure history; behavioral health diagnoses; trauma history involving animals; phobias; relevant medications] (Include only items relevant to AAT safety and participation.)
• Social/Environmental Context: [Living situation; caregiver support; school/work context; animal exposure history including current pets and prior adverse experiences; environmental factors relevant to AAT]
• Baseline Measures: [Measure name — score — date — interpretation] (Include only if administered; omit section if none.)

Objective Evaluation

• Mobility/Balance/Fall Risk: [Gait/transfer observations; balance status; assistive devices; fall risk indicators]
• Upper Extremity Function: [ROM, strength, coordination, grasp-release relevant to planned tasks] (Include if task-based activities anticipated.)
• Communication and Cognition: [Ability to understand and follow safety directions; attention; impulse control; memory]
• Sensory Considerations: [Tactile, auditory, visual sensitivities; tolerance of proximity and movement; startle response]
• Standardized Tests: [Tool name — score — functional interpretation] (Include only if administered; omit if none.)
• Functional Performance Observations: [Current abilities; assistance levels; activity tolerance; behavioral/affective presentation; barriers and facilitators]
• Safety-Relevant Findings: [Skin integrity concerns in likely contact areas; lines/tubes/equipment at risk; infection control flags including fever, active infection, isolation status]

AAT Screening

Indication for AAT

• Target Domains: [engagement / anxiety reduction / motor participation / social interaction / communication / self-regulation / other]
• Clinical Rationale: [Why AAT is appropriate now: patient preference, motivational factors, barriers addressed, expected contribution to functional goals]
• Role of AAT: [adjunct to established plan of care / primary intervention focus]

Human Factor Screening

(Document Yes/No/Unknown/Not assessed for each item; add brief explanation and mitigation plan if positive.)

• Allergies to relevant species: [Yes / No / Unknown / Not assessed] — [Details and mitigation if Yes]
• Asthma/reactive airway disease: [Yes / No / Unknown / Not assessed] — [Triggers, control status, mitigation]
• Fear/phobia or trauma history involving animals: [Yes / No / Unknown / Not assessed] — [Exposure plan or defer]
• Immunocompromised/high-risk status: [Yes / No / Unknown / Not assessed] — [Medical clearance required; mitigation]
• Open wounds/burns/rashes in contact areas: [Yes / No / Unknown / Not assessed] — [Covering required or avoid contact]
• Current infection symptoms/fever: [Yes / No / Unknown / Not assessed] — [Defer AAT until resolved]
• Cognitive/behavioral safety risks: [Yes / No / Unknown / Not assessed] — [Supervision level and boundaries]
• Fall risk for ambulation-based activities: [Yes / No / Unknown / Not assessed] — [Assist level, device, environment modifications]

Setting and Infection Prevention

• Location suitability: [Appropriate / Not appropriate] — [Space, flooring, access considerations]
• Hand hygiene plan: [Before and after contact for patient, staff, and handler]
• Contact restrictions: [Avoid saliva/face-licking; no contact with urine/feces; no animal contact with dressings/lines]
• Isolation/protective environment constraints: [None / Present — details and approvals]
• Cleaning/disinfection plan: [Per facility protocol]

Animal Team Confirmation

• Therapy animal team credentialed per facility policy: [Yes / No / Pending]
• Handler presence with active supervision planned: [Yes / No]

(If any critical safety item is Unknown/Not assessed, add to Plan: "Complete before first animal contact.")

Assessment

[Clinical impression summarizing baseline impairments and functional impact; factors affecting participation and safety]

AAT Determination: [AAT appropriate / AAT appropriate with precautions / AAT not appropriate at this time] — [Specify precautions if applicable; if not appropriate, document rationale and what would change determination]

Goals

Short-Term Goals

• [Target behavior/function; metric; performance criterion/assistance level; timeframe; context] (Frame as patient outcomes; AAT is the means.)
• [Additional STG as needed]

Long-Term Goals

• [Target behavior/function; metric; performance criterion/assistance level; timeframe; context]
• [Additional LTG as needed]

(If consult-only without planned ongoing therapy, replace Goals section with Recommendations: [Recommendations for AAT participation, precautions, and referral/coordination].)

Plan

• Planned Services: [AAT integrated into discipline-specific therapy / referral to appropriate provider]
• Frequency and Duration: [Frequency, duration, and planned re-evaluation point]
• Intervention Approach: [individual / group]; [in-room / common area]; [graded exposure / task-based activities]
• Progress Tracking: [Measures to be repeated and schedule]
• Precautions and Mitigation Strategies: [Allergy/asthma mitigation; boundaries; line/tube protection; wound coverage]
• Coordination Needs: [Notify nursing/provider/infection prevention; obtain clearances; schedule with handler]
• Contingency Criteria to Pause/Stop AAT: [Patient distress; respiratory symptoms; animal stress cues; safety events]
• Education Provided: [Topics covered with patient/caregiver]
• Referrals/Clearances Needed: [Medical clearance; allergy testing; behavioral support; other] (Omit if none.)
• Follow-up: [Next visit timing; re-evaluation date]

Clinician Signature: [Name, credentials] — [Date/Time]