Classic form

Occupational therapy intake form built on a daily living grid

An occupational therapist is asked to change how a day works, so the intake has to describe the day rather than the diagnosis. This eighteen field intake form takes an eight task support grid, the equipment already in the house, and the funding with its plan dates, before the first home visit is booked.

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Top of the occupational therapy intake form built on a daily living grid example — The top of the form as it renders. The image was generated for this example.

The form itself

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Referral and intake

Everyday OT, Geelong. One form per participant. If you are completing this on somebody else's behalf, say so in the sixth question and sign at the end as their representative.

Participant details

Participant name *

First

Last

Date of birth *

Best contact number *

Email for correspondence *

Address, including suburb, state and postcode *

Who is completing this form, and their relationship to the participant *

Funding

How is occupational therapy being funded? *

NDIS, plan managed

NDIS, self managed

NDIS, agency managed

Home Care Package

Medicare chronic disease referral from a GP

Department of Veterans Affairs

Private, paying myself

Insurer or workers compensation

Plan or funding start date *

Plan or funding end date *

Plan manager or support coordinator, name and contact

Why you are asking for OT

The answers below are health information. They are read by the treating occupational therapist, kept in the practice record, and included in reports only where the funding body requires one. A report written for a funding body is shown to you before it is sent.

Diagnoses or conditions relevant to this referral *

Goals, in the participant's own words *

A normal day

Answer each row for how the task goes on a normal day, not on the best day or the worst one. Needs equipment means it is managed with a rail, a board, a stick or similar. Needs prompting means the steps are physically possible but do not happen without a reminder.

How much help does each task take? *

	Independent	With equipment	With prompting	Hands on help	Not able
Showering and drying
Dressing, including shoes and fastenings
Preparing a hot meal
Moving around inside the home
Getting in and out of the house
Getting to the shops or an appointment
Managing money, mail and appointments
Work, study or volunteering

Equipment already in use *

Walking stick

Four wheel walker

Manual wheelchair

Powered wheelchair or scooter

Shower stool or bench

Grab rails

Toilet frame or raised seat

Hospital bed or pressure mattress

Hoist or transfer board

Communication device or app

Nothing yet

What is the home like? *

Steps at the front or back entrance

Stairs inside the home

Narrow doorways or hallways

A step into the shower, or a bath only

Rented, so changes need the owner's permission

Shared with family who provide support

Lives alone

None of these apply

Appointments and the team

Where should the first appointment happen? *

At home, which is usually the most useful

At the clinic in Geelong

At school or an early learning centre

At the workplace

By video call to start with

Who else is already involved? *

Specialist or rehabilitation consultant

Physiotherapist

Speech pathologist

Psychologist or counsellor

Support workers

Another occupational therapist, now or recently

Nobody else yet

Consent

By signing you confirm the information is accurate and consent to assessment and therapy. You also consent to the therapist contacting the professionals named above and, where the funding requires it, writing a report for the funding body. Reports are shown to you before they are sent. Consent can be withdrawn in writing at any time.

Signature of the participant or their representative *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Participant nameNameRequired
Date of birthDateRequired
Best contact numberShort textRequired
Email for correspondenceShort textRequired
Address, including suburb, state and postcodeShort textRequired
Who is completing this form, and their relationship to the participantShort textRequired
How is occupational therapy being funded?Single choiceRequired: Options: NDIS, plan managed · NDIS, self managed · NDIS, agency managed · Home Care Package · Medicare chronic disease referral from a GP · Department of Veterans Affairs · Private, paying myself · Insurer or workers compensation
Plan or funding start dateDateRequired
Plan or funding end dateDateRequired
Plan manager or support coordinator, name and contactShort text
Diagnoses or conditions relevant to this referralLong textRequired
Goals, in the participant's own wordsLong textRequired
How much help does each task take?Rating gridRequired: Statements:
Showering and drying
Dressing, including shoes and fastenings
Preparing a hot meal
Moving around inside the home
Getting in and out of the house
Getting to the shops or an appointment
Managing money, mail and appointments
Work, study or volunteering
Equipment already in useMultiple choiceRequired: Options: Walking stick · Four wheel walker · Manual wheelchair · Powered wheelchair or scooter · Shower stool or bench · Grab rails · Toilet frame or raised seat · Hospital bed or pressure mattress · Hoist or transfer board · Communication device or app · Nothing yet
What is the home like?Multiple choiceRequired: Options: Steps at the front or back entrance · Stairs inside the home · Narrow doorways or hallways · A step into the shower, or a bath only · Rented, so changes need the owner's permission · Shared with family who provide support · Lives alone · None of these apply
Where should the first appointment happen?Single choiceRequired: Options: At home, which is usually the most useful · At the clinic in Geelong · At school or an early learning centre · At the workplace · By video call to start with
Who else is already involved?Multiple choiceRequired: Options: GP · Specialist or rehabilitation consultant · Physiotherapist · Speech pathologist · Psychologist or counsellor · Support workers · Another occupational therapist, now or recently · Nobody else yet
Signature of the participant or their representativeSignatureRequired

What each block of this form collects

Five identity fields and then a sixth that most intake forms leave out: who is filling this in, and what they are to the participant. It is answered self about half the time and the other half it is a daughter, a nominee or a support coordinator, which changes who the therapist rings back. Funding comes next, and the plan start and end dates sit on one row because the gap between them is the whole runway for the work. The clinical block is two open questions, diagnoses and goals, with goals asked in the participant own words and shown as four example sentences rather than a category list. The grid, the equipment list and the home questions are the assessment prompt.

The Australian pieces on this form

The funding radio names eight real pathways and three of them are NDIS management types, because plan managed, self managed and agency managed decide who the practice invoices and how long it waits to be paid. A Home Care Package sits beside them for older participants, a Medicare chronic disease referral for the ones reaching an occupational therapist through a GP, and Veterans Affairs for the entitlements that run separately again. The plan end date is asked as a required field because funding here does not roll over: an assessment booked three weeks before a plan ends is a different job from one booked in the first month, and the thank you screen tells the participant to say so on the phone. Occupational therapists in Australia are registered with the national board, and NDIS registered providers work to the commission practice standards.

How to adapt this form

A paediatric service replaces the daily living grid with a school day version, covering dressing, lunch box, handwriting, sitting in a group and playground, and adds the teacher as a named contact with a consent tick for talking to them. A hand therapy clinic drops the home access block entirely and adds a dominance question, a splint history and a return to work date, since the assessment is about one limb rather than one house. An aged care assessment service keeps the grid and adds a falls question, how many in twelve months and whether any needed an ambulance, because that single number decides how urgent the home visit is.

What makes this form work

Eight tasks, five levels of support

Showering through to work or study, each rated independent, with equipment, with prompting, hands on help or not able. That grid is the assessment prompt and the funding evidence at once, and it takes a participant two minutes rather than the twenty a conversation would.

Goals are shown as sentences, not categories

Shower without help. Get back to the shops on my own. Cook dinner twice a week. The placeholder prints four real goals in a participant voice, which is what the field is asking for, and it produces answers a therapist can actually work towards.

Equipment already in the house is a tick list

Ten items from a walking stick to a hoist, plus a nothing yet option. Knowing what is already there stops the first visit recommending a shower stool that has sat in the bathroom for a year, and it tells the therapist what the house has been through.

Questions people ask

Why does an occupational therapy form ask about tasks rather than symptoms?

Because the goal of the work is a task, not a symptom. Whether someone can shower, dress, cook and leave the house is what the therapy changes and what a funding body reads, and a diagnosis on its own predicts none of it. Two people with the same condition can sit at opposite ends of the same grid row.

What does with equipment mean on the support grid?

That the task is managed alone once a rail, a stool, a board or a stick is in place. It is a distinct answer from hands on help, because the person is independent, and from prompting, where the body can do it but the sequence does not start on its own. Separating those three is what the grid is for.

Why ask for the plan start and end dates?

Because they set the runway. Funding here is granted for a period and does not carry over, so an assessment three weeks before an end date is a different piece of work from one at the start of a new plan. Both dates are required fields and the follow up call confirms them before anything is booked.

Who signs when the participant cannot?

A representative, and the signature field says so in its label. The sixth question records who they are and what their relationship is, so the file shows on its face whether a nominee, a guardian or a family member signed. Where a formal appointment exists, the practice asks for that paperwork at the first visit.

Does the participant see a report written for the funding body?

Yes, and the consent paragraph commits to it in those words: reports are shown to the participant before they are sent. That matters because a funding report describes somebody at their least capable, which is the version that gets funded and is not the version anyone wants to read about themselves unannounced.

Why is the first appointment usually at home?

Because the house is the thing being assessed. Step heights, doorway widths, where the bathroom is and how far the letterbox sits from the door cannot be measured in a clinic. The form offers clinic, school, workplace and video as alternatives, and marks the home option as the one that is usually most useful.

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Sources

Written and checked by the OneCraft team. Last checked 29 September 2026.