Occupational Therapy Evaluation Form
A complete initial and comprehensive OT evaluation template — occupational profile, ADL/IADL performance, body functions, clinical impression, goals, and plan. Free to download.
- Occupational profile and ADL / IADL performance grids
- Body-function measures with right / left columns
- Goals table with baseline, target, and target date
| Area | Assist | Device | Notes | Sign |
|---|---|---|---|---|
| Areas assessed | ||||
A full evaluation, start to finish
Structured around how OT evaluations are documented for payers and care teams — so nothing gets missed.
- Occupational profile: roles, routines, and priorities
- ADL and IADL performance with assist levels
- Body-function measures, right and left
- Cognition, vision, and sensation checklist
- Goals table plus frequency, duration, and plan
Who it’s for
Adult OTsRehab teamsHome health OTsOutpatient clinicsClinic ownersIf you evaluate adults across settings, this template keeps every evaluation consistent and defensible.
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
Does this work for both initial and comprehensive evaluations?
Yes — the same template covers both. Use the sections that apply to your setting and leave the rest blank.
What do the assist-level abbreviations mean?
The key is printed on the form: I = independent, S = supervision, MinA / ModA / MaxA for minimum, moderate, and maximum assist, and D = dependent.
Will this meet my payer’s documentation requirements?
It captures the elements most payers look for — profile, objective measures, impression, goals, and plan. Requirements differ by payer and state, so check yours and adapt before you rely on it.
Can I record my own outcome measures?
Yes. The body-functions table is deliberately open, so you can enter whichever standardized measures your clinic uses.
What happens after the evaluation is written?
On paper, you re-type it into the chart. In Terapiq the evaluation becomes the goals, the first session note, and the CPT-coded superbill without re-entry.
Grab the form — it’s on us
Free, fillable, and ready to brand. Download it now and see how much easier this can be.