An occupational therapy evaluation records who the client is, what they need and want to do, what gets in the way, and the plan to close the gap. Copy the free template, see two filled examples, and check what each part of the evaluation needs.
Blank occupational therapy evaluation template
FreeOCCUPATIONAL THERAPY EVALUATION Client: [Name] Date of birth: [Date] Date of evaluation: [Date] Referral: [Referral source, reason, and the question to answer] Diagnosis: [Medical or developmental diagnosis] Setting: [Hospital, clinic, home, school, or community] Therapist: [Name, credentials] OCCUPATIONAL PROFILE Reason for referral: [Concerns in the client's or family's words] Occupational history: [Roles, routines, work, school, leisure, valued activities] Priorities: [What the client most wants to do, or do better] Supports and barriers: [People, services, and personal factors that help or hinder] Relevant history: [Medical history, medications, precautions, prior therapy] ENVIRONMENT AND CONTEXT Home, school, or work: [Layout, stairs, bathroom, kitchen, classroom or workspace set-up] Equipment in use: [Adaptive equipment, mobility devices, technology] Safety: [Hazards, falls, emergency plan, who is available to help] OCCUPATIONAL PERFORMANCE ADLs: [Feeding, grooming, bathing, dressing, and toileting, with the assist level and cues for each] IADLs: [Meal preparation, medication management, home management, shopping, community mobility] Functional mobility and transfers: [Bed, toilet, tub or shower, car, with the assist level] Work, school, or play: [Performance in the client's main roles] Rest and sleep: [Sleep pattern and night-time routines that affect function] PERFORMANCE SKILLS AND CLIENT FACTORS Motor skills: [Reach, grip, coordination, balance during tasks] Process skills: [Attention, sequencing, organizing, problem solving during tasks] Social interaction skills: [Communication and interaction during tasks, if relevant] Body functions: [ROM, strength, sensation, vision, endurance, pain] Cognition: [Orientation, memory, executive function, safety awareness] STANDARDIZED ASSESSMENTS Assessments used: [Name, score, and what it shows for daily function] ASSESSMENT Summary: [Main occupational performance problems and what is causing them] Strengths: [What the client brings that will help] Rehab potential: [Good, fair, or poor, and why] GOALS Short-term goal 1: [Occupation-based, measurable, with a time frame] Short-term goal 2: [Occupation-based, measurable, with a time frame] Long-term goal 1: [Occupation-based, measurable, with a time frame] Long-term goal 2: [Occupation-based, measurable, with a time frame] PLAN Frequency and duration: [Sessions per week, number of weeks] Interventions: [Occupation-based activity, ADL or IADL training, therapeutic exercise, orthoses, environmental changes, education] Equipment and environment: [Recommendations and referrals] Agreement: [Client, family, or caregiver agreement with the goals and plan] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Home visit, community occupational therapy
82-year-old woman referred by her family physician after a fall in the bathroom at night 3 weeks ago; bruised left hip, no fracture. Widowed and lives alone. Her daughter lives 20 minutes away and visits twice a week. Retired teacher who values cooking for herself, her book club, and walking to the corner store. Since the fall she has been afraid to shower and has stopped going out. Priorities: shower safely, keep cooking, and stay in her own home. History: osteoarthritis of both knees, macular degeneration, hypertension. Takes 7 regular medications from an organizer her daughter fills.
Ground-floor apartment with 3 entrance steps and one rail. Bathtub with a shower over it and glass doors, no grab bars. Low toilet with no rails. Loose rugs in the hall and dim lighting between the bedroom and bathroom. Cane used outdoors only. Phone kept in the kitchen; no personal alarm.
Feeding, grooming, and upper body dressing: independent. Lower body dressing: modified independent, seated on the bed, slow with socks. Bathing: washing at the sink since the fall; a simulated tub transfer needed contact guard assist, and she could not safely lift her leg over the tub edge. Toileting: modified independent, pushes up from the sink edge. Meal preparation: made tea and toast safely, but unsteady carrying a hot drink while walking. Medication management: takes the right doses from the organizer. Shopping: done by her daughter since the fall. Sleep: up twice a night to use the toilet.
Motor: reaches the floor only with a reacher; slow to stand from the low toilet. Process: plans and sequences meal tasks well. Body functions: knee pain 4/10 on stairs; reduced central vision, reads large print only; grip reduced on both sides. Lying BP 138/78, standing 132/76 after 3 minutes, no dizziness. Cognition: alert and oriented; recalls safety advice better when it is written down.
Montreal Cognitive Assessment 24/30. Timed Up and Go 16 s with a cane. Falls Efficacy Scale-International 34, high concern about falling. Home safety checklist: 6 hazards found.
Night-time fall linked to a low toilet, a tub without grab bars, dim lighting, rugs, reduced vision, knee pain, and getting up twice a night. Fear of falling has narrowed her routine to the home. Main occupational performance problems: bathing, toilet transfers, carrying things while walking, shopping, and outings. Strengths: manages daily tasks safely, motivated, supportive daughter. The MoCA is below the usual cut-off; she is safe with routine tasks, and the result was shared with her physician for follow-up. Rehab potential: good.
Short-term, 2 weeks: transfer in and out of the tub with a bath bench and grab bar, with supervision; walk from bed to toilet at night with night lights and a clear path, independently. Long-term, 6 weeks: shower independently with the bench, a hand-held shower, and grab bars; carry drinks safely with a lidded cup or a trolley; walk to the corner store with her cane, first with her daughter and then alone; wear a personal alarm every day.
Weekly home visits for 6 weeks. Ordered a tub transfer bench, a hand-held shower, 2 grab bars, a raised toilet seat with arms, and night lights; rugs removed with her agreement. Transfer training, safe carrying, pain and energy management, and a graded plan for outings. Personal alarm options given to her and her daughter. Asked her physician to review her medications and her night-time toilet trips; referred to physical therapy for balance and strength. She and her daughter agree with the goals and plan.
School-based occupational therapy, grade 2
7-year-old boy in grade 2, referred by his teacher with his parents’ consent for slow, hard-to-read handwriting. Finishes about half of his written class work and avoids drawing. Reads well; loves building sets and soccer. His parents say he can’t yet do up buttons or tie laces, and holds his fork in his fist. Born at term, no medical diagnoses, and passed vision and hearing screening this year. Priorities from his teacher and parents: writing others can read, finishing class work, and changing for gym on his own.
Class of 24. His desk and chair are too high, and his feet don’t reach the floor. Copies from a board at the front of the room. Standard pencils and lined paper. Gym twice a week, with 5 minutes to change in a busy room.
Handwriting: copied a 3-line sentence in 4 minutes; classmates take about 2. Letter size varies, b and d reversed, uneven spacing, and words drift off the line. Cutting: stays within 1 cm (0.4 in) of a straight line; can’t follow a circle. Dressing: does up large buttons slowly; can’t tie laces and wears hook-and-loop shoes. Lunch: opens most containers; needs help with tight lids.
Motor: thumb-wrap grasp on the pencil with the wrist bent, heavy pressure, and hand fatigue after 5 minutes. Weak in-hand manipulation; turns the pencil with his other hand. Slumps after 10 minutes at his desk. Process: understands tasks, follows 2-step directions, and keeps his materials organized. Social: works well with classmates; frustrated during writing. Loses his place when copying from the board.
Beery-Buktenica Developmental Test of Visual-Motor Integration, 6th edition: visual-motor integration standard score 82, below average; visual perception 98, average; motor coordination 78, low. Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition: fine manual control standard score 38, below average.
Fine motor and visual-motor delays that limit handwriting, cutting, and fasteners. Visual perception is average, so the difficulty lies mainly in motor coordination and hand strength, with poor seating adding to fatigue. Strengths: good reading, language, and attention, keen to improve, and a supportive family and teacher. Impact: finishes about half of his written work and needs help changing for gym.
Short-term, 8 weeks: use a functional tripod grasp with a pencil grip for 10 minutes of writing; copy a 3-line sentence in 3 minutes with 80% of letters correctly sized and on the line. Long-term, end of the school year: write a 5-sentence paragraph others can read, with correct size and spacing on 4 of 5 lines; button a shirt and change for gym independently within 5 minutes.
30 minutes of direct OT a week at school for 12 weeks, plus consultation with his teacher. Fine motor strengthening, in-hand manipulation, multisensory handwriting instruction, and cutting and fastener practice. Classroom: lower his chair and add a footrest; trial a slant board, raised-line paper, and a pencil grip; give him a copy at his desk instead of the board. Home: 10 minutes a day of play with putty, tongs, and building sets, plus button practice. Recommendations shared with the school team; parents and teacher agree. Re-assess in 12 weeks.
Who the client is as a person who does things: their roles, routines, and what they most want to get back to.
Avoid: Jumping straight to impairments. Without the profile, the goals end up being yours, not the client’s.
Where the client lives, learns, or works, and what about that place helps or hinders.
Avoid: Assuming a transfer that is safe in the clinic is safe at home. See the real setting, or ask detailed questions about it.
How the client does the activities that matter, with the help and equipment they need.
Avoid: Rating ADLs from report alone when you could watch the task. Say which you did.
The skills you see during tasks, and the body functions and cognition that explain the difficulties.
Avoid: Listing factors with no task attached. Say which activity each one affects.
Named tools that back up what you observed, with the score and what it means for daily life.
Avoid: Copying item-level results into the note. Give the score and its meaning.
Short-term and long-term goals built on the client’s priorities, measurable, with a time frame.
Avoid: “Increase grip strength” as an OT goal on its own. Write the task it serves.
Without the client’s roles, routines, and priorities, the goals end up being yours, not theirs.
Name the assessment and give the score with what it shows for daily life. A number alone tells the reader little.
“Increase grip strength” isn’t an OT goal on its own. Write the occupation it serves: “Open a jar independently with an adaptive opener.”
A transfer that works in the clinic may not work in the client’s bathroom. Assess the real setting, or ask detailed questions about it.
For children, and for adults who need help, record what the people around them report and agree to.
Vero Scribe writes the evaluation in your template from the session conversation, with the client’s consent, or from your dictation, in more than 60 languages. You edit the goals and plan, then copy it into your EMR or export it to PDF or Word.
The referral, the occupational profile, the environment, ADL and IADL performance with assist levels, performance skills and client factors, standardized assessments, your assessment of the main problems, goals, and the plan.
A summary of the client’s occupational history, roles, routines, interests, and priorities, and of what helps or gets in the way. It shapes the goals, so it comes first.
It depends on the client and setting: cognitive screens such as the MoCA, fear-of-falling scales, visual-motor tests such as the Beery VMI for children, and client-rated measures such as the COPM. Use them to support what you see in real tasks.
Base each goal on an occupation the client cares about, and make it measurable and time-bound: the task, the level of help or equipment, the standard, and the time frame.
Yes. Use the profile for the child’s school roles and the concerns of the family and teacher, describe the classroom as the environment, and write goals about school tasks. Follow your school system’s report format where it has one.
Yes. Copy it, or download it as a Word or text file. No account needed.
Function-focused session note with ADLs, IADLs, assist levels, cues, fine motor, and safety.
Periodic review with assist levels then and now, goal status with evidence, and the updated plan.
A worked OT note, with assistance and cueing examples.
Bring visit goals, previous records, and preferences into one intake note.
Worked notes across formats, with checks before you sign.
Notes, documents, and follow-up in one workspace.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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