--- title: "Free Occupational Therapy Intake Form Template | formformform" description: "Free occupational therapy intake form template. Record which daily living activities are affected, the home and work environment, adaptations and equipment…" url: "https://www.formformform.com/templates/occupational-therapy-intake-form" type: static generatedAt: "2026-08-23T18:56:58.727Z" --- [Templates](https://www.formformform.com/form-templates)/[Healthcare Forms](https://www.formformform.com/form-templates/healthcare-forms) # Occupational Therapy Intake Form Template Occupational therapy starts from activities, not from a diagnosis. This template asks which everyday tasks have become difficult — dressing, cooking, bathing, transfers, work, getting out of the house — then records the home and work environment, the adaptations and equipment already in place, sensory, movement and organisation concerns, who is around to help, and, in the person's own words, what they most want to be able to do again. [Use this template](https://app.formformform.com/templates/occupational-therapy-intake-form/use) Last updated 21 August 2026 ## Fields in this template - Name of the Person This Form Is About · required - Who is filling this in? · required The person named above · A family member or friend on their behalf · A paid carer or support worker · A professional making a referral - Your Name, If You Are Not the Person Named Above - Date of Birth - Email Address · required - Phone Number - Who Referred You, If Anyone - What made you seek occupational therapy now? · required - Which everyday activities are currently difficult? · required Getting dressed · Washing or bathing · Using the toilet · Eating and drinking · Preparing meals or cooking · Housework or laundry · Shopping · Managing money, bills or paperwork · Managing medication · Getting in and out of bed · Moving between bed, chair and wheelchair · Stairs · Getting in and out of the house · Getting in and out of a car · Driving · Using public transport · Writing or typing · Using a phone, tablet or computer · Tasks at work · School or study tasks · Hobbies, leisure or getting out socially · Sleeping or a settled routine · Looking after children or another family member · Looking after a pet - Tell us more about the hardest of those · required - What kind of home do you live in? · required House with stairs · House all on one level · Bungalow · Flat or apartment with a lift · Flat or apartment without a lift · Supported or sheltered housing · Residential or nursing home · Temporary, shared or hostel accommodation · Adapted or accessible housing · Other - Who else lives with you? I live alone · With a partner or spouse · With family · With housemates or others · In a shared care setting · Prefer not to say - Adaptations already in place at home Grab rails · Ramp · Stair lift · Through-floor lift · Raised toilet seat or toilet frame · Shower seat or bath board · Level-access shower or wet room · Profiling or hospital bed · Ceiling or mobile hoist · Widened doorways · Key safe or door entry system · Adapted kitchen worktops · Nothing yet - Equipment you currently use Walking stick · Crutches · Walking frame or rollator · Manual wheelchair · Powered wheelchair · Mobility scooter · Prosthesis · Splints or orthoses · Pressure-relieving cushion or mattress · Reacher or grabber · Adapted cutlery or kitchen equipment · Medication organiser or reminder · Glasses or low-vision aids · Hearing aids · Communication aid or app · Personal alarm or fall detector · None - Anything we should know before a home visit? - Work, Study or Main Daily Role - Your work or study environment, and any adjustments already in place - Sensory concerns Sensitive to noise · Sensitive to bright light · Sensitive to touch, textures or clothing · Sensitive to smells or tastes · Seeks movement, pressure or deep touch · Reduced feeling in the hands or feet · Dizziness or balance problems · Changes in vision · Changes in hearing · None of these - Movement and physical concerns Weakness · Reduced grip or hand function · Tremor · Stiffness or reduced range of movement · Fatigue that limits what I can do in a day · Pain that limits activity · Poor balance · Falls · Difficulty with coordination · Breathlessness on effort · Difficulty swallowing · None of these - Thinking, memory and organisation concerns Remembering appointments or tasks · Concentrating for long · Planning or working through a task in order · Getting started on things · Finding words · Following spoken instructions · Keeping track of time · Feeling overwhelmed by decisions · Getting lost in familiar places · None of these - Falls in the last 12 months None · One · Two or three · More than three · Not sure - Who supports you day to day? · required - Do you have a carer? No · Yes — a family member or friend, unpaid · Yes — a paid carer or agency · Yes — both · I am a carer for someone else as well - Relevant medical conditions, recent hospital stays or upcoming operations - What do you most want to be able to do again, or do more easily? · required - Communication, language or access needs for your appointment - Before You Submit · required I understand this form is used to prepare for an appointment, that it is not a request for urgent or emergency care, and that nobody may read it before the appointment takes place. ## Who uses this template Independent and private occupational therapists · Community and social care occupational therapy teams · Hospital discharge and reablement services · Neurological and stroke rehabilitation services · Hand therapy and upper limb services · Paediatric occupational therapy services · Vocational rehabilitation and return-to-work services · Housing adaptation and equipment assessment services ## About this template An occupational therapy intake form asks a different question from every other clinical intake. It is not primarily interested in what is wrong; it is interested in what the person can no longer do, where they are trying to do it, and what is already in place to help. That is why this template opens with a long activities checklist rather than a medical history, and why the environment questions carry as much weight as the symptom ones. The three-part structure follows the way an occupational therapy assessment actually works. First the occupations: two dozen everyday activities, ticked freely, followed by a required box asking the person to describe the hardest one in their own words. Then the environment: the type of home, the adaptations already fitted, the equipment already used, and a plain practical field about steps, parking and access before anyone turns up for a home visit. Then the person: sensory, movement and organisation concerns as three separate checklists, alongside falls, the support network, and whether a carer — paid or unpaid — is involved. The organisation checklist carries a note in the field itself saying it is a list of everyday difficulties and not a cognitive assessment, because a list of memory and attention problems is very easy to mistake for a screening test. This is a template, not a validated assessment. Have a qualified occupational therapist review and adapt it before you use it with clients — a paediatric service, a stroke rehabilitation team and a housing adaptations service will each need a different subset, and the wording should match the outcome measures and the service model you already use. formformform hosts every form in the EU and handles submissions under GDPR, and optional end-to-end encryption can be switched on per form before responses start. Neither the template nor the platform makes any service compliant with HIPAA, SOC 2, ISO 27001 or any other framework, and nothing here substitutes for an assessment — providers are responsible for validating their own legal and regulatory requirements. ## 13 form ideas you can build with this template ### Community Occupational Therapy Referral Intake Collect the activities affected and the home setup before a community OT decides whether the first contact is a visit, a call or an equipment order. ### Hospital Discharge OT Assessment Form Record the home environment, existing adaptations and who is around to help, so a discharge plan is not built on assumptions about the house. ### Housing Adaptation Assessment Intake Capture home type, stairs, existing rails and ramps, and the transfers that are failing, ahead of an adaptations assessment. ### Stroke Rehabilitation Intake Form Use the movement and organisation checklists alongside the activities list to prepare a first neurological rehabilitation session. ### Paediatric Occupational Therapy Intake Keep the proxy questions, trim the activities list to dressing, feeding, school and play, and let a parent describe the hardest part in their own words. ### Vocational Rehabilitation Intake Form Combine the work environment field with the activities list to plan a phased return that reflects the actual job, not the job title. ### Hand Therapy OT Intake Form Cut the mobility items and keep grip, writing, typing, dressing and cooking for an upper limb caseload. ### Reablement Service Intake Form Record which self-care tasks currently need help and what equipment is already in the house before a short-term reablement package starts. ### Home Visit Preparation Form Use the access field for steps, parking, pets and entry arrangements so the first visit is not wasted at the front door. ### Assistive Equipment Assessment Intake List what the person already uses before recommending anything new, and pair it with the transfers and mobility answers. ### Neurodivergent Adult OT Intake Use the sensory checklist and the organisation checklist together to plan support around environment and routine rather than diagnosis. ### Private OT Practice Enquiry Form Let a self-referring client describe what they want to be able to do again before the first paid appointment is booked. ### Carer-Completed Intake Form Give a relative or paid carer a form that records who they are and their relationship, so the clinical team reads the answers in the right voice. ## What's included A 24-option activities-of-daily-living checklist as the required backbone of the form, covering self-care, domestic, community, work and leisure tasks Explicit "who is filling this in" question, so a proxy completing it for a relative or client is recorded rather than assumed Home type, adaptations already fitted and equipment already used as three separate questions, so nothing is recommended twice A practical pre-home-visit access field for steps, parking, pets and entry arrangements Sensory, movement and organisation concerns as three separate checklists, with a plain note that the third is not a cognitive assessment Support network and carer status asked directly, because recommendations that need a second pair of hands depend on it Work and study environment captured with the adjustments already in place, not just the ones missing A required goal field in the person's own everyday words Prominent emergency notice above every question Free with unlimited submissions, hosted in the EU, with optional end-to-end encryption per form ## How to create an occupational therapy intake form 1. 1 Click "Use this template" to load the occupational therapy intake form into your free formformform account. 2. 2 Have a qualified occupational therapist review the wording and the activities list before you publish it, and match it to the outcome measures your service already uses. 3. 3 Trim the activities checklist to your caseload — a paediatric service will replace half of it with school, play and self-care tasks, and a hand therapy service will cut most of the mobility items. 4. 4 Decide whether the proxy questions stay. Services that only ever see self-referring adults can delete the "who is filling this in" pair; discharge and social care teams should keep them. 5. 5 Add conditional logic in the editor if you want the proxy name field to appear only when someone else is completing the form — templates cannot ship with branching, so this is a step you add after cloning. 6. 6 Add an Upload field in the editor if you want photographs of the home environment, doorways or existing equipment before a visit. 7. 7 Turn on end-to-end encryption for the form in your account settings before you share the link, if you want each answer sealed in the browser before it is stored. 8. 8 Share the link at referral or on the waiting list confirmation, and set notifications so the assessing therapist has it before the visit is booked. ## Best practices for your occupational therapy intake form Have an occupational therapist sign this off before it goes live. It is a well-structured starting point, not a validated assessment tool the activities list and the concern checklists should be adapted to your service model and your scope of practice. Keep the activities checklist required and everything under it optional. The list is the part that turns a referral into a plan; the concern checklists below it are useful context, not gatekeeping. Ask what is already in place, not just what is missing. Adaptations, equipment and workplace adjustments are all asked separately for this reason recommending a grab rail that was fitted last year is the fastest way to lose a client's confidence. Do not let the organisation checklist read as a cognitive screen. Keep the field note saying it is a list of everyday difficulties and is not scored, and never report the ticks as though they were an assessment result. Record the proxy properly. When a relative or a carer completes the form, their answers describe the person from outside knowing who wrote it changes how you read every answer. Keep the home visit access field. Steps, parking, an intercom and a dog are the four things that most often waste a visit, and none of them are clinical. Build the plan from the goal field. It is the only field written entirely in the person's own words, and 'be more independent' is a sign the question needs asking again in the appointment, not a usable goal. Turn on end-to-end encryption before you share the link. This form collects a detailed picture of someone's daily life at home enable it in your account settings first, because encryption is opt-in per form and freezes once the first response arrives. Validate your own compliance obligations separately. This template does not make a service HIPAA compliant and represents no certification. ## Frequently asked questions Is this occupational therapy intake form template free? Yes. Use it, customise it and collect unlimited submissions at no cost, with no per-submission fees. Can I use this form as it is? Not without review. It is a starting point written to be adapted, not a validated assessment — have a qualified occupational therapist check it against your service model, your outcome measures and your scope of practice before you publish it. Why does it start with activities rather than medical history? Because occupational therapy starts from occupations. The activities checklist is what turns a referral into a plan; medical conditions are asked later and deliberately narrowly, limited to what affects daily activities. Can a family member or carer fill it in for someone? Yes, and the form records that explicitly. A required question asks who is completing it, with an optional field for their name and relationship, so a proxy's answers are never mistaken for the person's own. Is the thinking and memory checklist a cognitive assessment? No. It is a list of everyday difficulties, it is not scored, and the field says so in the form itself. It indicates which daily tasks to look at first — it does not screen for or indicate any diagnosis. How is this different from the speech therapy or general patient intake templates? The speech therapy template is built around a single communication concern and a referring physician. The general patient intake is built around demographics, insurance and medical history. This one is built around a checklist of everyday activities, the home and work environment, and equipment and adaptations already in place — none of which appear on either of the others. Can clients send photos of their home before a visit? Not on this template as it ships, because templates cannot include an upload field. Add an Upload field to your own copy in the form editor — formformform supports uploads on any form at up to 2 MB per file, and they remain encrypted on end-to-end encrypted forms. Is this form HIPAA compliant? No form makes a service HIPAA compliant by itself. formformform hosts in the EU, handles submissions under GDPR and offers optional per-form end-to-end encryption; your own obligations depend on your full workflow and should be checked with your own advisers. ## Related templates [Healthcare Forms Physiotherapy Intake Form Collect complaint, mechanism, pain scores, aggravating factors and goals before a first physiotherapy appointment.](https://www.formformform.com/templates/physiotherapy-intake-form)[Healthcare Forms Speech Therapy Intake Form Gather client history and communication concerns before a first speech therapy session.](https://www.formformform.com/templates/speech-therapy-intake-form)[Healthcare Forms Medical Equipment Request Form Process durable medical equipment requests with prescriber and insurance details.](https://www.formformform.com/templates/medical-equipment-request-form)[Healthcare Forms Patient Intake Form Collect patient info, medical history, and insurance before the appointment.](https://www.formformform.com/templates/patient-intake-form)[Healthcare Forms Privacy-First Patient Intake Form Collect only what a first visit needs, plus a privacy acknowledgement.](https://www.formformform.com/templates/privacy-first-patient-intake-form)[Healthcare Forms Podiatry Intake Form Collect the foot complaint, diabetes status, circulation and sensation symptoms, daily footwear and standing hours before a first podiatry appointment.](https://www.formformform.com/templates/podiatry-intake-form)[Healthcare Forms Dietitian & Nutrition Intake Form A non-judgemental dietitian intake covering a typical day of eating, medical context, food access, cooking facilities and cultural requirements.](https://www.formformform.com/templates/dietitian-nutrition-intake-form) ## More Healthcare form templates - [Dermatology Intake Form template](https://www.formformform.com/templates/dermatology-intake-form) - [Couples & Family Therapy Intake Form template](https://www.formformform.com/templates/couples-family-therapy-intake-form) - [Patient Information Update Form template](https://www.formformform.com/templates/patient-information-update-form) - [Medical History Form template](https://www.formformform.com/templates/medical-history-form) - [Health Screening Questionnaire template](https://www.formformform.com/templates/health-screening-questionnaire) - [Vision Care Patient Intake Form template](https://www.formformform.com/templates/vision-care-intake-form) - [Chiropractic Patient Intake Form template](https://www.formformform.com/templates/chiropractic-intake-form) - [Vaccination Record Request Form template](https://www.formformform.com/templates/vaccination-record-request-form) - [Appointment Request Form template](https://www.formformform.com/templates/appointment-request-form) - [Dental Patient Intake Form template](https://www.formformform.com/templates/dental-patient-intake-form) [View all Healthcare form templates →](https://www.formformform.com/form-templates/healthcare-forms) Start with the Occupational Therapy Intake Form template Free forever. 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