Distinction Between "Formal Evaluation" (Diagnostic Label) and "Functional Assessment" (Detailed Level of Functioning)

Currently we do not provide "Formal Evaluation" aka Diagnostic labelling services, but we do provide "Functional Assessment" services as part of creating targeted, customized programs to meet clients needs. The distinction between these two terms can be confusing for people outside of the care professions, so we hope to clarify the difference to help you determine if our services are what you need, or if you need to be referred to another type of service provider for a formal diagnosis before we can provide you with our services.

We have received a lot of phone calls and emails in recent weeks asking for "a diagnosis" service aka formal evaluation related diagnostic services. Some include for courtrooms, others for schools, and others for insurance purposes. Diagnostic labeling services are outside of our scope of practice. We provide Functional Assessment services to meet individual needs.

Many people are confused about the difference between a "Formal Evaluation" diagnosis and a "Functional Assessment".

Most insurance companies, courts, schools, and other organizations require a formal diagnostic term in order to provide certain services, adaptations, or permissions.  For example, in educational settings, the purpose of a formal evaluation is to determine whether your child has a disability that qualifies for special education and related services.  That is outside our scope of practice.

If you need a legal courtroom or other document providing a diagnostic term such as  "ADHD", "ASD", "Depression", "Bipolar", "Muscular Dystrophy", "Spinal Cord Injury", "PTSD", "Brain Injury", etc., then we can refer you to other providers for that documentation, because that type of initial diagnostic labeling is outside the scope of our practice.

If you would like us to provide a customized care program to help improve you or your loved-one's quality of life, then we can help you, by taking the diagnostic information you already have from another care provider, and then using our functional assessment tools to create a targeted program to meet your needs. We use the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICD & ICF). For example, relatd to a Mucular Dystrophy (MD) diagnosis from another provider, our functional assessment might determine power of muscles of left arm moderate impairment (WHO ICF b7301.2) and power of muscles in lower half of the body complete impairment (WHO ICF b7303.4), which lets us know what kinds of adaptations to take into consideration for our programs, and targeting specific needs.

Our Standards of Practice

Our services conform to the American Therapeutic Recreation Association's Standards of Practice.

This includes:

  1. Assessment
  2. Treatment Planning
  3. Plan Implementation
  4. Re-assessment and Evaluation
  5. Discharge/Transition Planning
  6. Prevention, Safety Planning, & Risk Management
  7. Ethical Conduct
  8. Written Plan of Operation
  9. Staff Qualifications and Competency Assessment
  10. Quality Improvement
  11. Resource Management
  12. Program Evaluation and Research


Where people get confused is with #1 Assessment: "The recreational therapist receives and responds, consistent with standards, regulatory requirements and policies for the setting, to requests, including referrals and physician orders, for assessment and treatment; and conducts an individualized assessment to collect systematic, comprehensive and accurate data necessary to determine a course of action and subsequent individualized treatment plan. Under the clinical supervision of the recreational therapist, the recreational therapy assistant, commensurate with qualifications, assessed competency and defined clinical supervision, assists the recreational therapist in collecting systematic, comprehensive and accurate data. "

The key concept is that we work as partners with many other professions that provide a formal diagnostic term, and then we provide the formal functional assessment to customize a program specific to a client's needs.

Examples of Formal Evaluation vs. Functional Assessment

Many insurance companies will not cover services if you do not have a formal diagnostic label. So it is usually required that you first go to a licensed provider to receive the diagnostic term and general recommendations first, then come to us for the formal assessment that creates a customized program specific to meeting your needs.

Below are some examples that may help clarify the difference and process for you.

Example #1 - Physical Therapy Diagnosis

A Physical Therapist provides a client with a diagnosis something like "Abdominal Hernia" with the relevant codes. They may assign some general or specific exercises, and supervise those exercises during initial treatment. Then as the client makes practice under the care of the PT, they may want to begin to formulate a longer-term care plan to keep building up strength and healing without exacerbating the injury. Often they will prescribe a regimen of exercises to continue with over the next 6 months. However research shows that many patients, once no longer having to regularly check in with the PT, will not be consistent in their exercises due to decreasing intrinsic motivation, and without finishing the prescription (somewhat like finishing your antibiotic prescription for example), are more likely to re-injure and be back again. So, a PT may, in partnership with other professionals, ask us to help create a transition plan that involves assessing the client's leisure and recreational interests, and create a program plan that meets the PT's prescription with the intrinsic motivational needs of the client. Research shows this greatly improves the likelihood the client will continue their exercises because of a higher level of enjoyment and closer match to intrinsically motivated interests, and so have lower levels of re-injury by finishing their strengthening rehabilitation program completely.

Example #2 Mental Health Diagnosis

A mental health health professional, such as a psychiatrist or psychology, may be asked to perform a formal diagnosis for a client, whether for personal reasons, for legal/court reasons, or other reasons. One example might be lead to a formal diagnosis by the mental health professional of Autism Spectrum Disorder (ASD).  There will likely be recommendations for medication, various therapeutic treatment programs, etc. We would then be brought in, either by the mental health professional as a recommendation, or by request of a prospective client. We can not provide the diagnosis of "ASD", but we would, based on the mental health professional's diagnosis and report information, perform a very detailed functional assessment telling us exactly what level of functioning the client has in many areas, to help us create a customized program to help target specific goals outlined by the mental health professional. For example "improve social skills", "decrease stereotyped behaviors", etc. We would perform functional and recreational interest assessments, and then create a program to help the client work toward meeting these goals. For example, research shows that tabletop role-playing games (RPGs) are indicated to be extremely helpful in addressing social skills development for many populations  including those with a diagnosis of ASD. We would then provide a customized RPG program to help them address this issue, which may also incorporate positive behavior modification aspects such as token economy rewards, in-game positive & negative reinforcement, etc.

Example #3 Medical Diagnosis

A Medical Doctor (M.D.) may have received a client with reports of progressive muscle weakness and determined (possibly with the help of other specialists) a diagnosis of Muscular Dystrophy (MD) in a young child. There are many types of MD, and a wide range of treatments available. One of the recommendations for many is to increase their social and physical engagement. Many patients with MD experience significant fatigue, and embarrassment at being in social situations, and so will often withdraw socially, and due to the fatigue experience a rapid downward spiral in physical activity which accelerates the deterioration of these disorders. Often professionals will prescribe something like "engage in regularly social programs" and "engage in regularly physical activity", possibly with some specific areas to target.  The doctor may refer the client to us directly, or the client may find us through other means. We would then take the doctor's diagnosis and relevant records and perform functional and baseline assessments. Then we would create a customized program to meet the client's needs. Examples of what we might include could be: weekly tabletop role-playing game (TRPG) for social engagement (we can provide expertise, training, and adaptive equipment that might not be available in other TRPG venues), and/or a live-action role-play (LARP) game that involves more strenuous physical activity such as a "boffer" LARP using foam swords and shields (as we have done for the Muscular Dystrophy Association). If these activities are in line with client's interest, they are very likely to regularly stay engaged in these activities in spite of their fatigue and other symptoms, and we will help them transition to engaging in these activities in the general community so that eventually they can continue on their own without need of our supervision.

Example #4 Educational Settings

A client may have  a student that is struggling in school. The school officials recommend a formal diagnostic assessment. The student is first taken to their General Practitioner (GP), who suspects Attention Deficit Hyperactivity Disorder (ADHD) and possibly other learning disabilities (LD). Some GP's are willing to make an ADHD diagnosis on the spot, others are more cautious due to lack of specialized training and will recommend a referral to an ADHD diagnostic specialist. If we receive a referral from a client from their GP of ADHD and they have not seen another specialist first, we will need to have a conversation with the GP first to determine their area of expertise. If they have sufficient training for an informed ADHD diagnosis, then we will proceed from there, if however we feel that it may be outside of their scope of knowledge, we may defer accepting the client and recommend they get a more definitive (second opinion) from a specialist, and we can help with that referral process. For example we highly recommend Spokane's Neuroeducation for very detailed diagnoses. Once there is a diagnosis from a qualified specialist, then we will accept the client, gather the documentation from the assessment, perform some additional functional assessment on our part if needed including leisure & recreation assessment, and then create a customized learning program to help the student improve their behavior, attention span, turn taking, impulse control, basic math skills, reading skills, etc.


There are many other populations we could provides examples for, but we hope this helps clarify the distinction between "Diagnosis" and "Functional Assessment", and the scope of our practice.





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