Occupational Therapy Neuro Rehabilitation Intake Form
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Occupational Therapy Neuro Rehabilitation Intake Form
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This specialized occupational therapy intake form is tailored for practitioners working with patients recovering from neurological events or managing progressive neurological conditions. The form systematically captures critical information about the patient's neurological diagnosis, onset date, medical interventions, and specific functional limitations affecting activities of daily living, instrumental activities, and cognitive-perceptual skills.
The template includes detailed sections for assessing upper extremity function, coordination, sensation, visual-perceptual deficits, cognitive status, and compensatory strategies currently in use. It addresses specific concerns relevant to neuro rehabilitation such as neglect, apraxia, executive function deficits, and safety awareness. The form also captures home environment details, caregiver support, therapy goals, and prior rehabilitation history to establish a comprehensive baseline for treatment planning and measuring functional outcomes.
What's included
- Neurological diagnosis and onset details
- Functional limitations assessment
- Cognitive and perceptual screening
- Upper extremity function evaluation
- Activities of daily living status
- Home environment and safety assessment
- Caregiver support information
- Prior therapy and rehabilitation history
- Current adaptive equipment use
- Patient therapy goals and expectations
Who uses this template
- Stroke rehabilitation clinics
- Brain injury recovery centers
- Neurological specialty OT practices
- Inpatient rehabilitation hospitals
- Home health neuro OT services
All form fields
10 fields across 3 pages. Customize any field after signing up.
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