Occupational Therapy Consent Form Template
A consent template covering evaluation and treatment, telehealth, information sharing, photography, and financial responsibility — with an authorized-contacts table. Free to download.
- Separate check boxes for each type of consent
- Authorized contacts and information-release table
- Signature block for client, guardian, and witness
| Name | Organization | Relationship | Purpose | Sign |
|---|---|---|---|---|
| Contacts authorized | ||||
Consent, clearly separated
Each permission is its own check box, so consent is specific rather than all-or-nothing.
- Evaluation and treatment consent
- Telehealth and remote session consent
- Information exchange with named providers
- Photography and video, clinical or marketing
- Financial responsibility acknowledgement
Who it’s for
Clinic ownersSolo practitionersFront desk staffPediatric clinicsTelehealth providersA clean starting point you can adapt to your practice and your state’s requirements.
Love the form? You’ll love not needing it.
The template is great on paper. Terapiq does the same job digitally — no lost sheets, no manual tallies, no chasing signatures.
Capture it in seconds
Fill it in from any device — Terapiq handles the totals, dates, and formatting automatically.
Signatures & audit trail
Sign-offs, dates, and details are captured and time-stamped — ready whenever someone asks.
One place for your clinic
Forms live alongside scheduling, notes, and billing — not in a folder of loose PDFs.
One platform, the whole clinic
This form is just the start. Here’s what else stops being paperwork.
Book in one drag
Click-and-drag appointments, online self-scheduling, and automatic reminders that cut no-shows — across every therapist, room, and location.
Explore scheduling →Notes that draft themselves
Document during the session and let the note assemble itself — goals, minutes, and CPT codes included. Review, sign, done.
See OT documentation →The note becomes the bill
CPT-coded superbills straight from your documentation, live authorization tracking, and self-pay or insurance set per service.
Explore OT billing →More for occupational therapy clinics
🧩 OT practice software
The full picture: scheduling, goals, documentation, authorizations, and billing built around occupational therapy.
See the OT platform →💳 OT billing
CPT-coded superbills, authorization and unit tracking, and pay type set per service — not per client.
Explore billing →📅 Therapy scheduling
Drag-to-book appointments, client self-scheduling, and reminders that keep your calendar full.
Explore scheduling →Reading for OT clinic owners
Form FAQ
Is this template legal advice?
No. It’s a general starting point, not legal advice. Consent requirements vary by state, payer, and setting — have your own advisor review it before you put it into use.
Why is each permission a separate check box?
Because consent should be specific. Someone can agree to treatment without agreeing to marketing photos, and the separate boxes make that distinction clear and documentable.
Does it cover telehealth?
Yes, telehealth and remote sessions have their own consent box, separate from in-person evaluation and treatment.
Who signs for a minor or a client with a representative?
There are fields for the parent, guardian, or representative along with their relationship to the client, plus a clinician or witness signature line.
How long does consent stay valid?
That depends on your policy and your state’s rules — many clinics refresh consent annually or when services change. Terapiq keeps signed consents on the chart so the front desk can see what’s current.
Grab the form — it’s on us
Free, fillable, and ready to brand. Download it now and see how much easier this can be.