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$15 - Book a Talk
Free Assessment form
To access your membership, please complete this quick assessment form
Full Name
Email Address
Phone Number
Address
Age Range
18–29
30–44
45–59
60+
Preferred Contact Method
Email
Phone
Text
What inspired you to explore therapeutic recreation programs?
Improve my overall well-being
Reduce stress
Be more active
Feel more connected socially
Explore new hobbies
Other
How would you describe your current leisure lifestyle?
What types of activities interest you most?
Physical
Creative
Social
Educational
Outdoor
Other
What barriers make it difficult to engage in leisure?
Lack of time
Motivation
Financial limitations
Health issues
Transportation
Other
Do you currently participate in any hobbies or recreation?
Yes
No
If yes, please describe
Which LeisureWorksNY programs interest you most?
Mindful Motion
Artful Moments
The Leisure Lounge
What do you hope to gain from your sessions?
Self-discovery
Relaxation
Social connection
Wellness balance
Learning new skills
Is there anything else you’d like us to know?
I understand this form is confidential
I confirm my answers are accurate
Date
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