By the Templateez Team · Licensed Attorney · June 2026

Occupational Therapy Intake Forms: What to Capture Before the First Treatment Session

The referral says "evaluate and treat." It does not say that the patient cannot button a shirt, cannot hold a fork without pain, has not been able to work for three months because of a repetitive strain injury, and is terrified that this is permanent. The physician referral tells the occupational therapist what the diagnosis is. The intake form tells the occupational therapist what the patient's life actually looks like right now — what they can do, what they cannot do, what they used to do, and what they need to get back to doing.

An occupational therapy intake form bridges the gap between the medical diagnosis and the functional reality. It captures the activities of daily living that the patient struggles with, the work tasks they cannot perform, the home environment they need to navigate, and the goals that will define whether treatment is successful. Without this information at the first visit, the therapist is designing a treatment plan based on a diagnosis code rather than a person.

Referral and diagnosis information

Insurance authorization for occupational therapy requires a physician referral in most states and under most payer contracts. Your intake must capture the referral chain:

• Referring physician — name, practice, phone, fax, and NPI number. You will need this for every authorization request and every progress report.
• Primary diagnosis — ICD-10 code and description. The diagnosis must support the medical necessity of occupational therapy services. Common referral diagnoses include stroke, traumatic brain injury, orthopedic injuries, repetitive strain disorders, developmental delays (pediatric), and neurological conditions.
• Date of onset or injury — the date the condition began or the injury occurred. This anchors the treatment timeline and determines whether the case falls under workers' compensation, auto insurance, or standard health coverage.
• Surgical history related to the referral — if the patient had surgery (rotator cuff repair, carpal tunnel release, joint replacement), document the procedure, date, surgeon, and any post-surgical precautions or restrictions currently in effect.
• Authorization details — pre-authorization number if already obtained, number of visits authorized, authorization expiration date. Many payers require re-authorization every 10–12 visits, so tracking the count from intake prevents denial surprises mid-treatment.

Functional limitations: what the patient cannot do

This is what makes OT intake different from every other healthcare intake. The question is not "where does it hurt?" The question is "what can't you do?"

• Activities of daily living (ADLs) — dressing (buttons, zippers, shoelaces, overhead garments), bathing (reaching, gripping soap, stepping in and out of tub), grooming (brushing teeth, combing hair, shaving), feeding (cutting food, lifting utensils, drinking from a cup), toileting (clothing management, transfers, hygiene). Rate each on an independence scale: independent, modified independent, supervision, minimal assist, moderate assist, maximal assist, dependent.
• Instrumental activities of daily living (IADLs) — cooking, cleaning, laundry, driving, managing medications, using a phone, handling finances, shopping. These higher-level activities often reveal functional deficits that ADL screening alone misses.
• Work-related tasks — if the patient is employed or was employed before the condition, document their job title, physical demands (lifting, carrying, keyboarding, standing tolerance), cognitive demands, and which specific work tasks they currently cannot perform. This drives work hardening and return-to-work planning.
• Hand function — grip strength (dominant versus non-dominant), pinch strength (tip, lateral, palmar), coordination, sensation, and any specific hand-related limitations. For hand therapy cases, this section needs to be granular: which fingers are affected, which motions are limited, and what functional tasks are impaired.
• Cognitive and perceptual function — attention, memory, sequencing, problem-solving, visual-perceptual skills, and safety awareness. For neurological patients, cognitive screening at intake establishes the baseline that treatment progress is measured against.

Medical history beyond the referral

The referral addresses the primary condition. The intake needs the full picture because co-existing conditions affect treatment planning:

• Other medical conditions — diabetes (affects wound healing and sensation), cardiac conditions (affects exercise tolerance), respiratory conditions (affects endurance), arthritis (affects joint loading), osteoporosis (affects weight-bearing precautions).
• Medications — blood thinners (affect modality selection), pain medications (affect pain reporting accuracy), muscle relaxants (affect motor performance), and any medications that cause dizziness, drowsiness, or cognitive fog.
• Prior therapy — has the patient received OT or physical therapy for this or a related condition before? If so, when, where, for how long, and what was the outcome? Knowing what has already been tried prevents repeating unsuccessful interventions and tells you whether the patient has a frame of reference for what therapy involves.
• Assistive devices and adaptive equipment — splints, braces, reachers, adapted utensils, wheelchair, walker, shower bench. What does the patient currently use, and who prescribed or recommended it?

Home environment and living situation

Occupational therapy is about function in context. The context is the patient's home, workplace, and community:

• Home layout — single-story or multi-story? If multi-story, where is the bedroom, bathroom, and laundry relative to the main living area? Are there stairs at the entrance? Grab bars in the bathroom? A walk-in shower or tub-only?
• Living situation — lives alone, with spouse, with family, in an assisted living facility, or in a skilled nursing facility. The level of in-home support affects discharge planning and home exercise program design.
• Caregiver identification — if the patient has a caregiver, document who they are, their availability, and their ability to assist with exercises, transfers, and ADL tasks. Caregiver training is often part of the OT plan of care.
• Transportation — can the patient drive themselves to appointments? If not, who provides transportation, and are there scheduling constraints?

Treatment goals: the patient's words

Insurance requires functional, measurable goals. But the starting point should be the patient's own description of what they want to get back to:

• Patient-stated goals — "I want to get back to work." "I want to be able to pick up my grandchild." "I want to cook dinner for my family again." These become the foundation for the measurable goals in the plan of care.
• Pain level — current pain at rest and with activity, on a 0–10 scale. Where the pain is located, what makes it better, what makes it worse. Pain that limits function is an OT treatment target.
• Prior level of function — what was the patient's functional level before the onset of the condition? Were they fully independent? Active? Working full-time? This establishes the ceiling for realistic goal-setting.

Insurance and authorization: the administrative backbone

An OT practice that does not capture insurance details at intake is an OT practice that discovers authorization problems after treatment has already begun:

• Primary and secondary insurance — carrier, plan, group number, member ID, and the subscriber's information if different from the patient.
• Workers' compensation — if work-related, capture the employer, claim number, adjuster name and contact information, and date of injury. Workers' comp claims have separate authorization requirements and different documentation standards.
• Auto insurance (PIP/MedPay) — if the condition resulted from a motor vehicle accident, capture the auto carrier, claim number, and policy limits. PIP coverage varies by state and may have visit limits that differ from health insurance. Chiropractic practices often see the same PIP patients and face the same authorization constraints.
• Visit limits and copay — document the patient's copay amount, any visit limits under their plan, and whether the visits are combined with physical therapy (many plans combine OT and PT into a single visit allocation).

Why OT intake is different

Most healthcare intake forms ask about symptoms. An occupational therapy intake form asks about life. The question is not "what hurts?" but "what can you not do that you need to do?" The intake captures function, independence, environment, and goals — the data that transforms a diagnosis code into a treatment plan designed around an actual human being's actual daily life. Speech therapy practices take a similar function-first approach, focusing on communication and swallowing rather than pain, but with the same emphasis on capturing what the patient can and cannot do before the first session begins.