Occupational Therapy Referral Checklist Form – Fill Out and Use This PDF

Occupational Therapy (OT) promotes an individual's maximum potential for independence and enhanced wellness. A key component is understanding how individuals manage daily tasks to achieve the highest standard of occupational functioning. Within OT practice, one essential part of helping clients reach their full occupational potential is the Checklist Form—a detailed questionnaire exploring various areas, including physical health, lifestyle habits, psychosocial history, and multidisciplinary assessment of individual strengths, severity, and functional narrative. Together, these serve to provide clinicians with critical points for documenting progress over time as well as make recommendations for further treatments with acknowledgment of any pre-existing physical disabilities or conditions. In sum, the OT Referral Checklist Form is vital to identify immediate needs that must be considered before delivering a sound treatment plan most likely to lead to quality outcomes.

Occupational Therapy Referral Checklist Form PDF Details

Are you considering occupational therapy for your patient? If so, it's important to be sure that the referral is handled properly. To ensure that communication between referring parties and the occupational therapist is clear and concise, a comprehensive checklist form should be completed. This post will provide an overview of what’s included in a typical Occupational Therapy Referral Checklist Form, as well as some tips on how best to fill one out. With this simple step-by-step guide, you can have confidence that all necessary information related to the referral process has been correctly documented. Read on for more details!

Question	Answer
Form Name	Occupational Therapy Referral Checklist Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Physical Therapy Referral Checklist Form, Occupational Therapy Referral Priority Checklist Form

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Occupational Therapy

Priority Checklist Guidelines

This form has been designed for occupational therapists to complete in discussion with someone who is already working with the client being referred

It is not intended to remove the need for a more in-depth assessment of occupational function, but to provide a starting point for the focus of intervention and to screen referrals in order that the best use of scarce occupational therapy resources can be made.

As such, the language of the form has been carefully chosen so that the items consist of commonly understood terms reflecting the focus of traditional occupational therapy. These are organised into four sections that correspond with themes from the Model of Human Occupation: volition, habituation, performance and environment. The occupational therapists’ knowledge of these items will assist them to make more detailed enquiries as to their clients’ precise needs

VOLITION

	Confidence	‘Personal causation’: appraisal of ability, expectation of success,
	Confidence	realism, understanding of strengths and limitations, sense of control

	Interest	enjoyment, satisfaction, curiosity, participation, choices, goals,
	Interest	preferences, sense of purpose, commitment
		preferences, sense of purpose, commitment
	HABITUATION

	Self-care	independence, activities of daily living

	Productivity	responsibilities, roles, routines
	(domestic/work/education)	responsibilities, roles, routines
	(domestic/work/education)
	Leisure	balance, structure, variety, occupational demands

	PERFORMANCE
	Interpersonal skills	‘Communication and Interaction skills’:
	Interpersonal skills	non-verbal skills, conversation, vocal expression, relationships

	Cognitive ability	‘Process skills’:
	Cognitive ability	knowledge, planning, organisation, problem-solving
		knowledge, planning, organisation, problem-solving
	Physical ability	‘Motor skills’:
	Physical ability	posture, mobility, co-ordination, strength, effort, energy
		posture, mobility, co-ordination, strength, effort, energy
	ENVIRONMENT
	Physical environment	facilities, opportunities, privacy, accessibility, stimulation, comfort,
	(home/work/place of study)	finance, aids and equipment, possessions, transport, safety
	Social support	family dynamics, friends, neighbours, peers, work colleagues,
	Social support	expectations and involvement
		expectations and involvement

Having identified the possible needs of the client, the occupational therapist is required to make a professional judgement regarding the need for occupational therapy intervention. This is not necessarily based on the number of ticks in the ‘Yes column’, but on the perceived urgency/severity of need that is most likely to be apparent in the comments section of the form

Occupational Therapy Referral

Priority Checklist

Name of client:		Name of worker with whom referral has been
	……………………………………	discussed:	…………………………………………

Date of birth:	____/ ____/ ____	Designation: ………………………………………..
Identity number: ……………………………………		Date:	____ / ____ / ____

Is there any indication that occupational therapy would be useful to help explore or support the following areas of functioning?

Yes No

Don’t know

Comments

MOTIVATION

Confidence

Interest

ROUTINE

Self-care

Productivity (domestic/work/education)

Leisure

PERFORMANCE SKILLS

Interpersonal skills

Cognitive ability

Physical ability

ENVIRONMENT

Physical environment (home/work/place of study)

Social support

IDENTIFIED NEED FOR OCCUPATIONAL THERAPY

No clear need for OT – no occupational needs identified

Need for minimal intervention/further assessment/consultative OT services to support wellness and/or prevent dysfunction.

Need for OT intervention to restore/improve function

Need for extensive OT intervention to improve function. Referral to follow-up services may also recommended.

Occupational Therapist: ……………………………..

Signature: …………………………………………..

Occupational Therapy Referral Checklist Form – Fill Out and Use This PDF

Occupational Therapy Referral Checklist Form PDF Details

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