Intake Forms for Occupational Therapists: Functional Assessment, ADL Documentation, and Goal-Setting

By Daniel Akselrod · July 2026

Occupational therapy is fundamentally about function — what a person can and cannot do in the context of their daily life, their work, and their environment. That makes OT intake uniquely demanding compared to other rehabilitation disciplines. A physical therapy intake can focus primarily on range of motion and strength measurements. An OT intake must capture how a person gets dressed in the morning, whether they can manage their own medications, whether their bathroom has a tub or a walk-in shower, and whether their employer can accommodate modified duties. The intake is not just a medical history — it is a functional portrait of the whole person.

Most OT practices use generic healthcare intake forms that capture demographics, insurance, and medical history but leave the therapist to assess functional status entirely during the evaluation. That approach wastes billable evaluation time on questions that could have been answered on paper before the session began. A purpose-built occupational therapy intake form front-loads the functional information so the evaluation session can focus on hands-on assessment, clinical reasoning, and treatment planning.

Referral and Diagnosis: The Clinical Foundation

Every OT intake starts with the referral. The referring physician’s name, practice, phone, and fax number are essential for coordinating care and sending progress reports — many insurance plans require regular updates to the referring provider as a condition of continued authorization. The primary diagnosis should include the ICD-10 code because insurance claims are built on diagnostic coding, and discrepancies between the referral diagnosis and the treatment diagnosis create billing complications.

Secondary diagnoses that affect function are equally important. A patient referred for hand therapy after a wrist fracture may also have diabetes (which affects healing time and sensation), rheumatoid arthritis (which affects joint protection strategies), or depression (which affects motivation and participation in the home exercise program). These comorbidities change the treatment approach even though they are not the primary reason for referral.

Date of onset or injury, relevant surgical history, and physician-imposed precautions must be captured before the first treatment session. Weight-bearing restrictions, cardiac precautions, fall-risk status, and cognitive precautions all constrain what activities the therapist can safely introduce during the evaluation. A therapist who learns mid-session that a patient has a sternal precaution from recent cardiac surgery has already wasted time planning activities that are now contraindicated.

Functional Status Assessment: ADLs, IADLs, and Beyond

The functional status section is the heart of an OT intake form and the section that distinguishes it from every other healthcare intake. Activities of daily living — bathing, dressing (upper body and lower body separately, because they require different physical demands), grooming, toileting, feeding, and transfers — should each have a current independence rating. A simple scale works well at intake: independent, needs setup or cueing, needs physical assistance, or dependent. This baseline rating establishes the starting point against which all progress will be measured.

Instrumental activities of daily living extend the assessment into community functioning: cooking, cleaning, laundry, medication management, money management, driving, shopping, and community mobility. For many patients — particularly those recovering from stroke, traumatic brain injury, or progressive neurological conditions — the IADL assessment reveals the functional deficits that matter most to the patient and their family. A patient who can dress independently but cannot manage their own medications or cook a meal safely is not ready to live alone, regardless of how their ADL scores look.

Current mobility status (ambulatory, wheelchair user, walker, cane) affects which activities are feasible and how the therapist sets up the treatment environment. Hand dominance and upper-extremity function — grip strength, fine motor skills, range of motion — are especially critical for upper-extremity rehabilitation, hand therapy, and return-to-work planning. Cognitive status including orientation, memory, attention span, problem-solving ability, and safety awareness should be screened at intake because cognitive deficits affect every other area of function and change the treatment approach fundamentally. Vision and perceptual status — visual field deficits, spatial neglect, depth perception problems — round out the functional picture.

Living Environment and Support Systems

OT is one of the only healthcare disciplines that treats the environment as a modifiable factor in the treatment plan. Your intake form needs to capture the patient’s home layout: are there stairs at the entry? Is the home single-story or multi-story? What is the bathroom setup — tub with a step-over, walk-in shower, grab bars present or absent? These details determine whether the patient can function safely at home with their current abilities or whether adaptive equipment and home modifications are needed.

Current adaptive equipment already in use should be inventoried: reachers, sock aids, shower chairs, long-handled sponges, raised toilet seats, button hooks, and built-up utensil handles. If a patient already has equipment, the therapist needs to know whether they are using it correctly, whether it is the right equipment for their current needs, and whether additional devices would increase their independence.

Caregiver availability is a critical planning variable. Who is helping the patient, how often, and with what tasks? A patient with a spouse who can assist with lower-body dressing has a different treatment trajectory than a patient who lives alone. Return-to-work goals require documentation of the job title, physical demands of the job, and whether the employer has offered or can accommodate modified duties. For pediatric patients, school-related goals — handwriting, scissors use, self-care at school, and playground participation — replace the work section.

Insurance and Authorization: The Administrative Reality

Insurance requirements in occupational therapy are complex and vary dramatically by payer. Medicare, Medicaid, private insurance, workers’ compensation, and auto insurance each have different documentation requirements, different visit limits, and different authorization processes. Many private plans require prior authorization before OT can begin, and treatment initiated without authorization may not be reimbursed retroactively.

Previous OT treatment must be documented: when, where, how many visits, and what was addressed. Insurance companies frequently deny coverage when a condition was previously treated, arguing that the patient has already received the benefit of OT for this diagnosis. Knowing the prior treatment history at intake allows the therapist to frame the current referral as addressing a new episode, a different functional deficit, or a change in status that warrants additional intervention.

Co-pay and deductible status affects the patient’s out-of-pocket planning and should be discussed at intake to avoid surprises. Many insurers also require standardized functional outcome measures at evaluation and discharge — knowing which measures are required at intake allows the therapist to administer the correct assessment tool during the evaluation rather than having to bring the patient back for a supplemental testing session.

Goal-Setting: Starting With What Matters to the Patient

The most effective OT treatment plans are built around goals that the patient identified, not goals that the therapist assumed. Your intake form should ask the patient, in their own words, what they most want to be able to do. The answer might be “button my own shirt,” “drive again,” “go back to work,” or “take care of my grandchildren.” These patient-stated priorities anchor the treatment plan and keep it meaningful.

Short-term goals (four to six weeks) should be measurable functional gains: “patient will independently don a pullover shirt within 3 minutes” rather than “improve upper extremity function.” Long-term goals should describe the expected functional status at discharge. Discharge environment — home, assisted living, skilled nursing, or rehabilitation facility — affects goal appropriateness. A discharge goal of independent meal preparation is appropriate for a patient going home but not for a patient discharging to a skilled nursing facility where meals are provided.

Family or caregiver goals should also be documented at intake because they sometimes differ from the patient’s goals and need to be reconciled. A patient may prioritize returning to a hobby, while the family is focused on safety and self-care independence. Identifying this disconnect early allows the therapist to address both perspectives in the treatment plan.

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