Pediatric OT Assessment Form
Complete this pediatric occupational therapy assessment to share the child’s background, functional concerns, priorities, and scheduling availability.
Patient & Referral Details
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Age
Parent/Guardian Name
*
Relationship to Child
*
Please Select
Mother
Father
Guardian
Other
Primary Reason for OT Assessment / Referral Concern
*
Preferred Contact Method
*
Phone
Email
Text Message
Other
Developmental Function Assessment
Developmental Function Ratings
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Fine motor skills
1
2
3
4
Gross motor skills
5
6
7
8
Sensory processing
9
10
11
12
Self-care / ADLs
13
14
15
16
Attention / participation
17
18
19
20
Emotional regulation
21
22
23
24
Current Difficulty and Examples
*
Rows
Current difficulty level
Example or observed behavior
Fine motor skills
25
Gross motor skills
26
Sensory processing
27
Self-care / ADLs
28
Attention / participation
29
Emotional regulation
30
Overall Functional Impact
Minimal impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is Minimal impact, 10 is Severe impact
Goals, Support Needs, and Scheduling
Top Therapy Priorities
*
Fine motor skills
Self-care skills
Sensory regulation
Attention and participation
Emotional regulation
Play and social skills
Other
Key Behaviors or Triggers to Be Aware Of
Current Supports or Services in Place
Preferred Appointment Days and Times
*
Monday morning
Monday afternoon
Tuesday morning
Tuesday afternoon
Wednesday morning
Wednesday afternoon
Thursday morning
Thursday afternoon
Friday morning
Friday afternoon
Weekend
Other
Additional Notes or Questions for the Therapist
Submit Form
Should be Empty: