Movement Assessment (Dance/Movement Therapy)

Date of service: [Date] | Start time: [HH:MM] | Stop time: [HH:MM] | Total duration: [Minutes]

Location/Setting: [Outpatient clinic / Inpatient unit / School / Rehabilitation program / Community setting / Other] | Visit type: [Initial assessment / Re-assessment / Consult]

Modality: [Individual / Group / Dyadic / Family] | [In-person / Telehealth]

Provider: [Name, credentials] | Participants present: [Client / Caregiver / Interpreter / Staff / Other]

Consent obtained: [Yes / No / Verbal / Written] | Touch consent reviewed: [Yes / No / N/A] | Safety precautions: [Fall risk / Mobility aids / Medical restrictions / None indicated]

Reason for Referral

[Referral source and clinical question, e.g., baseline movement repertoire, regulation capacity, body image, social engagement] (For re-assessments, state interval since prior assessment and purpose.)

[Client's stated concerns in own words] (Include only if explicitly reported.)

[Functional impact in daily life]

Relevant History

• [Movement-affecting medical conditions, pain, or orthopedic considerations]
• [Relevant psychiatric/behavioral health history]
• [Current medications affecting arousal, motor function, or coordination]
• [Developmental history if pediatric: motor milestones, sensory processing]
• [Movement/dance background, sports, physical activity patterns]
• [Cultural considerations affecting movement expression, touch, or space use]
• [Prior relevant therapies: PT, OT, psychotherapy] (Only if pertinent.)

(If any relevant item was not obtained, state "Not obtained" rather than leaving blank.)

Assessment Method

[Session structure and eliciting tasks used to observe movement, e.g., warm-up sequence, mirroring, rhythm entrainment, improvisation, grounding exercises, locomotor pathways, use of props]

[Music use: presence/absence, type/tempo, client- vs. therapist-selected]

[Therapist participation level, e.g., observing, co-moving, leading/following]

[Standardized tools administered, if any, e.g., MARA, KMP] (Name tool and purpose; summarize findings here or in Clinical Formulation.)

Movement Observations

(Document concrete, behaviorally anchored observations before interpretation. When using specialized terminology, include plain-language translation. Clearly distinguish observation from interpretation.)

General Presentation and Psychomotor State

• [Overall activity level and pacing; latency to initiate movement]
• [Gaze orientation and facial expressivity]
• [Posture/alignment and observable muscle tone]

Body Organization and Connectivity

• [Predominant initiation sites, e.g., distal-led vs. core-led] (Include plain-language translation.)
• [Sequencing across body segments; midline integration; cross-body coordination]
• [Stability-mobility patterns]
• [Breath visibility, breath-movement coordination, rhythmic capacity]

(Provide examples, e.g., "distal-led reaching with minimal trunk rotation; increased integration after grounding sequence.")

Effort and Dynamics

• Time: [Sudden / Sustained] [Observed tendency and variability; ability to shift on cue]
• Weight: [Light / Strong] [Modulation capacity]
• Space attention: [Direct / Indirect] [Precision vs. exploratory patterning]
• Flow: [Bound / Free] [Containment vs. fluidity; variability]

(Include plain-language translations, e.g., "bound flow (more controlled/contained movement).")

Space and Kinesphere

• [Kinesphere size: near/mid/far reach; consistency and factors affecting range]
• [Pathways: linear, curvilinear, varied]
• [Directionality and level changes]
• [Use of floor and environment; proximity patterns]

Shape and Expressivity

• [Shape qualities observed, e.g., rise/sink, spread/enclose, advance/retreat] (Add plain-language meaning.)
• [Expressive contour changes; congruence with affect]
• [Symbolic or thematic movement motifs] (Describe as observed without definitive interpretation.)

Movement Repertoire

• [Range of movement categories: locomotor, gesture, stillness, rhythm, play, relational]
• [Novelty vs. repetition; stereotypy; avoidance zones]
• [Ability to imitate, vary, and transition; responsiveness to cueing]

Regulation and Co-Regulation Capacity

• Baseline arousal: [State at session start with behavioral anchors]
• Up-regulation: [Ability to mobilize/increase intensity safely; strategies that supported change]
• Down-regulation: [Ability to settle/slow; strategies used; time course]
• Window of tolerance: [Signs of overwhelm or shutdown; recovery time]
• Co-regulation response: [Response to therapist rhythm, mirroring, pacing, proximity, verbal grounding]
• Observed triggers: [Antecedents observed, e.g., loud music, close proximity; include client report] (Do not assert causation.)

Relational Movement Patterns

• Engagement: [Approach/avoidance; initiation; responsiveness to invitations]
• Attunement and synchrony: [Mirroring tolerance; rhythmic joining; repair after mismatch]
• Boundaries: [Personal space negotiation; consent signals; ability to decline]
• Agency: [Leading/following; turn-taking; negotiation of choice]
• Communication style: [Gesture clarity; eye contact; vocalization; use of props to relate]
• Group dynamics: [Role in group; joining/leaving patterns; affect contagion] (Include only if group session.)

Clinical Formulation

Summary of Key Findings

• [Key movement pattern across body/effort/space/shape domains]
• [Key regulation capacity finding]
• [Key relational movement pattern]
• [Strength or resource observed]
• [Area of constraint or need]
• [Response to specific intervention or cue]

Formulation and Working Hypotheses

[Clinical hypotheses linking movement observations, client report, and history] (Anchor to observed behavior; label explicitly as hypotheses, e.g., "pattern may reflect protective strategy." Do not infer trauma history or diagnoses solely from movement.)

Strengths/resources: [Identified strengths and how they may support treatment]

Barriers/needs: [Movement, sensory, environmental, or cultural factors]

Limitations: [Assessment constraints, e.g., single session, space limitations, cultural considerations]

Risk Assessment

[No acute safety concerns identified] (Use if applicable.)

(If concerns present: [Risk type, e.g., falls, self-harm, agitation] | [Protective factors] | [Immediate plan])

Treatment Recommendations

• Modality and frequency: [Individual / Group / Dyadic / Family] | [In-person / Telehealth] | [Frequency and duration]
• Initial goals: [Measurable movement-based and functional outcomes]
• Intervention focus areas: [Mapped to findings, e.g., repertoire expansion, regulation skills, relational movement, body connectivity]
• Accommodations: [Touch boundaries, music sensitivity, pacing needs, mobility aids]
• Referrals/coordination: [PT, OT, psychiatry, psychotherapy, school team, etc.]
• Re-assessment plan: [Timeline and outcome tracking method]

Next Steps

• [Education provided to client/caregiver]
• [Home practice or between-session suggestions] (Only if agreed upon.)
• [Next session focus]
• [Team communication completed]
• [Follow-up scheduled: date/interval]