Occupational Therapy Consultation Form
Occupational therapy has the most honest success metric in healthcare: can this person do the things their life is made of? Not what the imaging shows, not what the lab values say — whether Mrs. Okafor can dress herself, manage her medications, and get to her Thursday volunteering. The discipline’s evaluation therefore has to capture something no other specialty measures quite the same way: the gap between the life a person has and the life they can currently manage alone.
This occupational therapy consultation form is the clinic’s own evaluation instrument — deeper than the referral that sent the patient, structured around the assessments that define OT practice. Where a referral summarizes why a patient is coming, this form builds the working baseline therapy runs on: functional performance across daily activities, the home environment therapy has to succeed in, and goals the client helps write so the plan is theirs.
The ADL and IADL Battery
The evaluation’s core maps performance across the two domains OT is organized around:
Activities of daily living — the fundamental self-care tasks: bathing, dressing, eating, toileting, grooming, transferring. Each is assessed for current level of independence, captured on a consistent scale so a re-evaluation eight weeks later measures the same thing the same way. Independence ratings are the field’s common currency; collecting them in identical structure across clients and visits is what makes progress visible.
Instrumental activities of daily living — the tasks that let someone live independently rather than merely function: cooking, managing medications, handling finances, using transportation, shopping, managing the household. IADL loss is usually the first sign that someone is quietly struggling at home, and it is the domain family members notice last because it fails privately.
A multiple choice battery keeps both domains scannable — assess, rate, move on — with conditional depth opening where the assessment finds problems: which part of dressing is hard, what compensations are already in use, what assistive devices exist and which are actually being used. A patient who reports difficulty with mobility should meet questions about equipment, not a wall of irrelevant follow-ups.
The Home Environment Walkthrough
Occupational therapy happens in kitchens and bathrooms, not treatment rooms — which makes the home environment assessment inseparable from the treatment plan. The form structures it: living situation, stairs and their railings, bathroom configuration, lighting, trip hazards, and whether the current setup supports or sabotages independence.
A long text section captures what a checklist cannot: the bathroom the patient avoids, the bedroom relocated downstairs, the doorway too narrow for the walker arriving next week. These observations become the home-modification recommendations, the equipment orders, and the caregiver guidance that make therapy stick after discharge — and documenting them at evaluation means the recommendations trace to a recorded assessment rather than a therapist’s memory.
Goals the Client Writes
An OT plan succeeds when its goals are the client’s own. I want to get stronger produces nothing; I want to braid my daughter’s hair again produces a treatment plan. The evaluation’s goal section is collaborative by design: a long text prompt invites the client to name what they want back, in their words, and the therapist structures it into measurable objectives from there — specific, achievable, time-bound, and tied to the ADL and IADL findings that make them realistic.
The client’s own phrasing is worth preserving verbatim in the record. When motivation sags in week five, being able to read back what they said they wanted — in their own words — is the most reliable re-engagement tool the discipline has.
Measuring Change Across the Episode of Care
An evaluation is only valuable if the next one compares against it. Three mechanisms make the comparison structural rather than aspirational:
- Identical scales at every assessment — the independence ratings, the goal ratings, the same questions in the same order, so week eight measures week one.
- Recall information carrying earlier answers forward — the re-evaluation opens with the client’s original goals on screen, turning a routine review into a visible progress conversation.
- Duplicated forms per assessment point — evaluation, re-evaluation, discharge — each with its own timestamped record, giving the clinic a clean measurement trail and the payer a documentation chain showing exactly why continued care was necessary.
All of it lands in one reviewable record the therapy team shares — including, in multidisciplinary settings, the role-based access that lets OT, PT, and speech each see the whole patient while protecting records appropriately. Related clinical formats are collected under healthcare form templates.
Frequently Asked Questions
What is the difference between an ADL and an IADL assessment?
ADLs are the fundamental self-care tasks — bathing, dressing, eating, toileting — that a person must do for themselves daily. IADLs are the higher-order tasks that independent living requires: cooking, managing medications and money, transportation, shopping. ADL assessment measures basic function; IADL assessment measures whether someone can sustain an independent life. OT plans typically target both, and losses in each imply different intervention strategies.
Who completes this form — the therapist or the client?
Both, by design. Demographics, history, and goal prompts suit client or caregiver completion before the appointment, often from home. The ADL/IADL ratings, environment observations, and clinical sections are completed by the therapist during the evaluation itself. The split lets the appointment spend its time on assessment rather than transcription.
How does the home environment section change treatment?
It converts therapy from theoretical to practical. A patient can master dressing on a treatment table and still fail in a bathroom with no grab bars and a towel bar where a rail should be. Documented environment findings drive the modification recommendations, equipment choices, and caregiver coaching that determine whether therapy gains survive at home.
Can this adapt to pediatric or neurology-focused practices?
The functional skeleton — performance, environment, goals — holds across populations. Pediatric practices extend the battery with play-based and school-task assessments; neurological practices add cognitive-perceptual sections. Duplicate the form per specialty and extend the assessment layer; the measurement structure stays constant.
How do re-evaluations stay comparable to the original?
Identical scales, identical questions, identical order — enforced by duplication rather than memory. Each assessment point gets its own form instance, and the series reads as a measurement trail: what was assessed, what changed, what the next phase targets. That trail is also what demonstrates medical necessity when payers review continued care.
What belongs in the goal section for insurance purposes?
Goals that are specific, measurable, achievable, relevant, and time-bound — but anchored to the client’s own stated priorities. Braid my daughter’s hair becomes: independently complete hair care sequence using adapted technique within six weeks. The payer sees a measurable objective; the client sees their life coming back.