BIG BAND MUSICAL INTERVENTION
Blank Sample Form
Evaluation of Effectiveness of the Intervention in Meeting Goals
Tea Group Name / Time:
Date:
Facility:
Residents will:
Desired outcomes and benefits:
1. Have an increase in positive mood
2. Have an increase in social interactions
3. Have an increase in memory of personal history
Other Group Goals to meet identified need or support identified strengths:
Check appropriate answer:
Were resident goals met?
Yes
No
# of residents meeting goal
1. Positive mood enhanced
2. Social interactions increased
3. memory of personal history revived
4. Discontinued intervention for __________________________ after ________ times because:
(resident name)
5. Modifications to intervention that worked for this group
a)
b)
6. Unanticipated results of intervention: