Intake Forms for Occupational Therapists: Functional Assessment and Treatment Planning

By Daniel Akselrod · July 2026

A referral comes in for a 72-year-old woman who fell at home and fractured her wrist. The orthopedist cleared her for outpatient OT. She arrives at your clinic and you start with the standard musculoskeletal intake — range of motion measurements, grip strength, pinch strength, edema assessment. All appropriate for the wrist. But twenty minutes into the evaluation, she mentions that the fall happened because she tripped on a throw rug while carrying laundry upstairs. She lives alone. Her daughter checks in by phone but lives two hours away. She hasn’t been able to cook for herself since the fall because she can’t open jars or hold a pan with her non-dominant hand.

The wrist is the diagnosis. The functional problem is that this woman can’t perform the daily tasks that keep her living independently. If your intake form only captures the orthopedic injury, you’ll treat the wrist. If your occupational therapy intake form captures the full functional picture — her ADLs, her home environment, her support system, her fall risk factors — you’ll treat the person. That distinction is what makes OT intake fundamentally different from physical therapy or any other rehab discipline.

How OT intake differs from PT

Physical therapists and occupational therapists share referral sources, treatment settings, and billing codes. They even share some assessment tools. But the intake focus is different in ways that matter clinically. PT intake centers on the body — joint range of motion, muscle strength, gait mechanics, pain levels. The goal is to restore physical function. OT intake centers on the person in their environment — what tasks they need to perform, what’s preventing them from performing those tasks, and what adaptations or compensatory strategies can restore their participation in daily life.

A PT evaluating a stroke patient measures shoulder flexion, grip strength, and ambulatory function. An OT evaluating the same patient asks whether they can button a shirt, cut food with a knife, write their name, manage their medications, use a phone, drive a car, or return to their job as an accountant. The physical impairments overlap, but the clinical questions are different, and the intake form has to reflect those different questions.

ADLs and IADLs: the core of OT intake

Activities of Daily Living (ADLs) are the self-care tasks that every person needs to perform: bathing, dressing, grooming, toileting, eating, and functional mobility (getting in and out of bed, on and off the toilet, in and out of a car). Instrumental Activities of Daily Living (IADLs) are the higher-level tasks that support independent living: cooking, cleaning, laundry, managing finances, taking medications, shopping, using transportation, and managing a household.

Your intake form should assess both categories, ideally with a rating scale for each task — independent, needs setup or cues, needs physical assistance, unable to perform. This baseline is not just clinically useful; it’s essential for insurance justification. Medicare and most commercial payers authorize OT based on functional deficits, not diagnoses. A fractured wrist alone doesn’t justify six weeks of OT. A fractured wrist in a patient who lives alone, can’t dress herself, can’t prepare meals, and is at risk for another fall does. Your intake form is where that functional story begins.

The ADL/IADL section should be specific enough to capture meaningful deficits but not so exhaustive that it takes 45 minutes to administer. Grouping tasks by category — self-care, home management, community participation, work/school — with a simple rating scale and a notes field for each group gives you the functional snapshot without turning the intake into a three-page checklist that overwhelms the patient before you’ve even started the physical evaluation.

Hand and upper extremity evaluation

Hand therapy is a major OT subspecialty, and many OT referrals involve hand, wrist, elbow, or shoulder pathology. Your intake form should include upper extremity-specific sections that capture dominant hand, the specific diagnosis (carpal tunnel, trigger finger, Dupuytren’s contracture, flexor tendon repair, distal radius fracture, rotator cuff repair, lateral epicondylitis), surgical versus non-surgical management, date of onset or surgery, and current splinting or bracing.

Functional hand assessment at intake focuses on grip patterns — power grip (holding a hammer), precision grip (picking up a coin), lateral pinch (turning a key), tip pinch (picking up a pin) — and bilateral coordination tasks. Can the patient open a jar, button buttons, tie shoes, type on a keyboard, use scissors? These questions go beyond the standard grip dynamometer measurement that any PT would do. They place the hand’s physical capacity in the context of the tasks the patient actually needs to perform.

Edema measurement (circumferential or volumetric), sensory testing (light touch, two-point discrimination, sharp/dull), and scar assessment (adherence, hypersensitivity, hypertrophic or keloid formation) are all relevant at intake for post-surgical hand patients. Documenting these baselines on the intake form gives you objective comparison points for progress notes and discharge summaries that insurers expect to see.

Sensory processing: the pediatric dimension

Pediatric OT is heavily focused on sensory processing — how a child receives, interprets, and responds to sensory input from their environment. A child who is sensory-seeking may crash into furniture, spin excessively, and chew on non-food objects. A child who is sensory-avoidant may refuse certain clothing textures, cover their ears in noisy environments, and have meltdowns during transitions. A child with poor sensory discrimination may have difficulty with handwriting because they can’t feel how hard they’re pressing the pencil, or may stuff their mouth with food because they can’t sense when it’s full.

Your pediatric OT intake form should include a sensory history section — ideally a parent-completed questionnaire that covers the seven sensory systems (visual, auditory, tactile, vestibular, proprioceptive, gustatory, olfactory) with examples of behaviors in each. Does the child avoid playground swings? Do they refuse to wear jeans or socks with seams? Do they seem to not notice when their hands are dirty or their face is messy? Do they have difficulty sitting still during meals or circle time?

This sensory profile is not a diagnosis — it’s a screening tool that helps you identify which sensory systems to assess more formally during the evaluation. But capturing it at intake, before the child even arrives for their first session, lets you prepare the treatment space (removing potential triggers for a sensory-avoidant child, having movement equipment ready for a sensory-seeking child) and sets the tone for a parent-therapist partnership that starts with the parent’s observations, not just the therapist’s clinical assessment.

Cognitive screening: memory, executive function, and visual-perceptual skills

OTs work with cognitive deficits across populations — stroke, traumatic brain injury, mild cognitive impairment, dementia, and developmental delays. Your intake form should include a cognitive screening section that flags patients who may need formal cognitive assessment during the evaluation.

For adult and geriatric patients, ask about memory (forgetting appointments, misplacing items, getting lost in familiar places, repeating questions), executive function (difficulty planning meals, managing medications, handling finances, making decisions, following multi-step instructions), and visual-perceptual skills (difficulty judging distances, bumping into doorframes on one side, trouble reading or finding items in a cluttered drawer). These questions are not a substitute for standardized cognitive assessments like the MoCA or the LOTCA, but they tell you whether cognitive testing should be part of your initial evaluation or whether the referral is purely physical.

For pediatric patients, cognitive screening at intake focuses on attention, sequencing, and problem-solving. Can the child follow two-step directions? Do they get lost in the middle of a multi-step task? Can they identify what comes next in a pattern? These questions, combined with the sensory profile, give you a working hypothesis about whether the child’s functional difficulties are primarily sensory, cognitive, motor, or a combination — which directs your evaluation plan.

Work demands and ergonomic assessment

Return to work is a primary outcome measure for working-age OT patients. Your intake form should capture the patient’s occupation, the specific physical demands of their job (lifting, carrying, keyboarding, gripping tools, overhead reaching, sustained postures), their current work status (working full duty, modified duty, off work), and their employer’s willingness to accommodate restrictions.

For patients with repetitive strain injuries — carpal tunnel, lateral epicondylitis, De Quervain’s tenosynovitis — the work demands section is where you identify the biomechanical exposures that caused the condition and will aggravate it if not addressed. A patient with carpal tunnel who keyboards eight hours a day needs a different treatment plan and a different prognosis conversation than a patient with the same diagnosis who does light assembly work. Your intake form is where you capture that context.

Ergonomic assessment questions at intake can also identify patients who would benefit from a workstation evaluation — an additional service many OT practices offer. If the patient describes wrist pain that started after switching to a new desk setup, neck pain from a monitor at the wrong height, or shoulder pain from reaching for a keyboard that’s too far away, those are ergonomic referrals hiding inside a clinical intake.

Home environment and adaptive equipment

For patients being discharged from a hospital or rehab facility, or for geriatric patients at risk for falls, the home environment section of your intake form captures critical safety information. Does the home have stairs? Are there grab bars in the bathroom? Is the bedroom on the main floor? Is the shower a walk-in or a tub? Are there throw rugs, poor lighting, or clutter in walkways?

Adaptive equipment already in use should also be documented. Does the patient currently use a reacher, a sock aid, a long-handled sponge, a raised toilet seat, a shower bench, a rolling walker, a wheelchair? Have they been issued equipment by a previous therapist that they’re not using? (This happens constantly — the patient was given a sock aid at discharge from inpatient rehab, it’s still in the box.) Knowing what equipment the patient has, what they’re actually using, and what barriers exist in their home lets you write a treatment plan that addresses the real obstacles to independence, not just the clinical deficits in the chart.

Assistive technology extends beyond low-tech adaptive equipment. For patients with significant upper extremity limitations, your intake should ask about voice-activated devices (smart speakers for home control, voice-to-text for communication), electronic aids to daily living, and any existing technology the patient uses that could be leveraged therapeutically. The line between speech therapy and OT blurs in the assistive technology space — SLPs focus on communication devices while OTs focus on devices that support task performance — and your intake should capture both to facilitate coordinated care when both disciplines are involved.

Insurance authorization and physician referral

OT services require a physician referral in most states and for most payers. Your intake form should capture the referring physician’s name, the referral date, the diagnosis code, and any specific treatment orders or precautions noted on the referral. Medicare requires a plan of care signed by the physician within 30 days of the initial evaluation — capturing the referral details at intake starts that clock and ensures the paperwork gets to the right physician for signature.

Insurance authorization adds another layer. Many commercial plans require prior authorization for outpatient OT, with authorization typically granted for a specific number of visits (8–12 is common for an initial authorization). Your intake form should capture the insurance carrier, the authorization number if prior auth was already obtained, the number of visits authorized, and any limitations on frequency or duration. Documenting this at intake prevents the unpleasant surprise of a denial three visits in because the authorization wasn’t obtained or the authorized visits have been exhausted. Browse the full form catalog to see how professional healthcare intake documentation handles these requirements.