Free occupational therapy template

Occupational therapy intake form and case history format

An occupational therapy intake form and case history format that families can fill in at home, with sample answers for each section.

Questions only, no checklists
Typical-day table families can fill
Works for children and adults

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What's inside

Reason for Referral
Health and Relevant History
Family and Home
A Typical Day
Self-care
Play, School, and Work
Sensory Preferences (as Reported)
Equipment and Current Supports

+ 2 more sections

Occupational Therapy Intake and Case History Form

Name		Date completed
Date of birth		Completed by
Relationship to client		Languages at home
Referred by		Preferred contact

Reason for Referral

What are your main concerns, and who suggested occupational therapy?

What would you most like occupational therapy to help with?

Health and Relevant History

Health conditions, hospital stays, medicines, allergies, and precautions

Has anything about early development or health worried you or a doctor? Please describe.

Reports from doctors, therapists, or school that you can share

Family and Home

Who lives at home, and who helps with daily care?

Languages spoken at home and at school, and the language the child or client prefers

Anything about the home that affects daily tasks, such as stairs or a shared bathroom

A Typical Day

Time of Day	What Usually Happens	What Goes Well	What Is Hard
Waking and morning routine
Mealtimes
School, work, or day activity
Afternoon and evening
Bedtime and sleep

Self-care

Activity	Does It Alone	Does It With Some Help	Someone Does It for Them	Comments
Eating and drinking
Dressing
Toileting
Bathing and grooming
Brushing teeth

Play, School, and Work

Favourite activities, play, friendships, and interests

School, college, or work: class or role, support in place, and any concerns raised by teachers or employers

Sensory Preferences (as Reported)

Situation	What You Notice	What Helps
Noise and busy places
Touch, clothing, and grooming
Movement, swings, and heights
Food textures and tastes
Lights and screens

Equipment and Current Supports

Equipment used now, such as seating, splints, a wheelchair, or adapted cutlery

Other therapies and supports, and how often

Family Priorities

Up to three things you would most like to change in daily life

Anything else you would like the therapist to know

Therapist Sign-off

Therapist	Designation	Registration	Date

How to fill it in

Reason for Referral
The family's main concerns in their own words, and who suggested OT.
More guidance
Ask the family to describe the main concerns in their own words and to say who suggested OT. When you review the form, note any difference between the referrer's concern and the family's. Leave their answer as written on the form itself.
Health and Relevant History
Health conditions, medicines, precautions and earlier reports, asked as open questions.
More guidance
Ask about health conditions, hospital stays, medicines, allergies, precautions and earlier reports, and invite the family to bring documents. Ask open questions about early development and any concerns, without listing ages or milestones. For adults, ask about the illness or injury, surgery and any restrictions the doctor has given.
Family and Home
Who lives at home, who handles daily care, and languages used.
More guidance
Record who lives at home, who handles each part of daily care, and the languages used. In joint families, the grandparent or helper who manages mornings may be the most important person for the plan. Ask about the home only where it affects daily tasks, such as stairs or a shared bathroom.
A Typical Day
What happens across a weekday, what goes well, and what is hard.
More guidance
The table walks through a weekday. For each part of the day, the family writes what usually happens, what goes well and what is hard. These answers often show the real priorities. Encourage short, concrete answers over general statements.
Self-care
The level of help for each self-care task, with the family's comments.
More guidance
Families mark the level of help for each task and add comments. Tell them there are no right answers. Add tasks that matter in the household, such as eating with the hand, managing a dupatta or lungi, or packing a school bag.
Play, School, and Work
Play, friendships and school support for children; work and household roles for adults.
More guidance
For children, ask about favourite activities, friendships and play, then school: type of school, class, any shadow teacher or special educator, and concerns raised by teachers. For adults, ask about work tasks, travel to work, household roles and hobbies.
Sensory Preferences (as Reported)
What the family notices in everyday situations and what helps, recorded as given.
More guidance
Ask what the family notices in everyday situations and what helps. Record answers as given; this section holds the family's observations and does not produce a result. Do not put items from a licensed sensory questionnaire here. If your clinic uses one, give it separately with its own instructions.
Equipment and Current Supports
Equipment, other therapies and supports in use, and what has or has not worked.
More guidance
List equipment in use now, other therapies and how often, school support and home adaptations. Ask what has worked and what has not, so you do not recommend something the family has already tried and set aside.
Family Priorities
Up to three things the family most wants to change in daily life.
More guidance
Ask the family to name up to three things they would most like to change in daily life. These become the starting point for the treatment plan. Finish with an open question for anything else they want the therapist to know.

Occupational therapy intake form and case history format: filled sample

Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.

Reason for Referral

'Teacher says he does not finish writing work. At home he takes very long to eat and still needs help in the bathroom.'

Health and Relevant History

Born early and stayed in the NICU for 3 weeks. Takes seizure medicine twice a day. Has a developmental paediatrician's report from last year.

Family and Home

Lives with parents, paternal grandparents and his uncle's family. Grandmother bathes and feeds him. Kannada at home, English at school, some Hindi with the helper.

A Typical Day

Morning: wakes at 6:00 and refuses to brush, so mother brushes for him. Goes well: eats breakfast quickly. Hard: getting into uniform before the van.

Self-care

Dressing: does it with some help. Comment: pulls on T-shirts; cannot do buttons or the school belt.

Play, School, and Work

Class 3 at a state-board school. Teacher says notebook work is often incomplete. Loves cricket and drawing; plays with cousins after school.

Sensory Preferences (as Reported)

Noise: covers his ears at the pressure cooker whistle and during festival crackers. What helps: holding his father's hand, going to a quiet room.

Equipment and Current Supports

Speech therapy weekly at another centre. Uses a pencil grip at school. Tried a weighted blanket last year; he would not stay under it.

Family Priorities

1. Eat lunch at school without help. 2. Get ready for school with less shouting. 3. Write his name and address.

OT case history form vs OT assessment report

	Case history / intake form	Assessment report
Completed by	Family or client, with the therapist's help if needed	The occupational therapist
Contains	Reported history, routines, preferences and priorities	Observations, test results as each manual reports them, interpretation and plan
Judgement	None; answers are recorded as given	Clinical interpretation by the treating OT
Timing	Before or at the first visit	After assessment sessions
Shared with	Kept in the clinic record	The family and, with consent, the school or referrer

Tips and mistakes to avoid

Do

Offer the form in the family's preferred language, or fill it in with them.
Send it a few days early so families can gather reports.
If families answer aloud, note who answered each section and in which language.
Go through it together at assessment; a two-word answer often hides a story.
In healhab, clinics can file completed paper forms in the patient's private document repository.

Avoid

Adding milestone ages, which turns a history form into a screening test.
Asking only about problems and skipping interests and strengths.
Not recording who completed the form.
Copying answers into the report without checking them in interview.

About this case history form

An occupational therapy intake form collects the background an OT needs before assessment: reason for referral, health history, who lives at home, a typical day, self-care, play, school or work, sensory preferences as the family describes them, equipment and the family's priorities. This free OT case history format asks questions only and gives no results.

Sent home before a first OT assessment
As an interview guide at the first visit
Adults referred after stroke, injury or surgery
A child moving from another service

Parents or adult clients complete the intake form before the first assessment, or the therapist fills it in with them. In India it is usually called a case history format.

It records home languages, who helps with daily care and the routines that matter. It holds questions only, with no milestones, age bands or test items; the OT interprets the answers during assessment.

Questions

What is an OT case history format?

The form or interview an OT uses to gather background before assessment: reason for referral, health history, family and home, daily routines, self-care, play, school or work, sensory preferences, equipment and priorities.

Who fills in the occupational therapy intake form?

Usually a parent or carer for a child, or the client for an adult. The therapist can also complete it with them at the first visit. Either way, record who answered.

Does the intake form include developmental milestones?

No. It asks open questions about development and health but lists no ages or milestones. The occupational therapist interprets the information during assessment.

Can I use this intake form for adults?

Yes. Skip the play and school questions where they do not apply, and add work, household roles, transport and the doctor's precautions.

Does the sensory section give a result?

No. It records what the family notices and what helps. It is not a sensory questionnaire, so give any licensed tool to the family separately.

Is there a filled sample of this case history form?

Yes. Each section guide shows a fictional sample answer, initials only, as a family might write it. The form has no interpretation section; the OT draws conclusions during assessment.

Can families fill in the form online?

Yes. It opens in the free editor without sign-up and downloads as a PDF. Drafts stay on the device used, so use the family's own device or a clinic computer.

More occupational therapy templates

Case history form formats for other therapies

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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