Pediatric Occupational Therapy Screening Form
A quick screen to decide whether a child needs a full OT evaluation — concern checklist, structured observations, and a clear referral outcome. Free to download.
- 16-area concern checklist across motor, sensory, and self-care
- Structured observation rows with concern flags
- Clear screening outcome and referral options
| Area | Observed | Concern | Notes | Sign |
|---|---|---|---|---|
| Areas screened | ||||
A fast screen that leads to a clear decision
Designed for classroom and clinic screens where you need an answer quickly.
- Concern checklist across 16 common areas
- Structured observation rows with concern flags
- Screening outcome: monitor, refer, or no concerns
- Recommendations and next steps
- Parent notification signature line
Who it’s for
School-based OTsEarly interventionPreschool programsPediatric clinicsScreening eventsPerfect for classroom screens, community events, or triaging a waitlist.
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
How is a screening different from an evaluation?
A screening is a quick check to decide whether a full evaluation is warranted — it isn’t diagnostic and doesn’t produce goals. The form states this on the page so families understand the difference.
How long does it take to complete?
Usually ten to fifteen minutes per child, including a short observation. It’s designed to be fast enough for classroom screening days.
Can a teacher or assistant fill it in?
The concern checklist can be completed by anyone who knows the child well. The screening outcome and referral decision should come from a licensed OT.
What happens if the outcome is “refer”?
You move to a full evaluation. There’s a recommendations section for next steps and a signature line confirming the family was notified.
Can I screen a whole classroom efficiently?
On paper, one sheet per child. Terapiq lets you screen, flag, and convert a referral straight into a scheduled evaluation without re-keying anything.
Grab the form — it’s on us
Free, fillable, and ready to brand. Download it now and see how much easier this can be.