Initial Occupational Therapy Assessment Report
Personal Details
Client’s Name:
%%FULLNAME%%
Claim Number:
%%CLAIMNO%%
Date of Birth:
%%CLAIMNO%%
Age:
(insert current age)
Address:
%%ADDRESS%%
Referred By:
%%REFERRERFULLNAME%%
Insurer:
%%REFERRERCOMPANYNAME%%
Insurer Contact:
(Insert insurer name)
Ph:
Fax: %%REFERRERFAX%%
%%REFERRERPHONE1%%
Date of Assessment:
(Insert date of assessment)
Date of Report:
6 May 13
BACKGROUND INFORMATION:
An initial occupational therapy assessment was undertaken at %%FIRSTNAME%%’s
home/ school on (insert date of assessment). (Insert name of people present) were
present for the assessment.
%%FIRSTNAME%% lives with (insert family names) and currently attends (school year)
at (school name).
%%FIRSTNAME%%’s mother reported the following concerns:
 Difficulties with

During the initial assessment %%FIRSTNAME%% presented as being….. He/ she was
able to…
Relevant Medical History
%%FIRSTNAME%% was diagnosed with (insert injury history)
%%FIRSTNAME%%’s previous therapy or treatment has included:

RESULTS FROM ASSESSMENT:
Fine Motor Skills
%%FULLNAME%%), Initial Occupational Therapy Assessment Report, (Insert date of report)
Gross Motor Skills
Visual Processing
Social Skills
Other Skills Assessed
Summary:
%%FIRSTNAME%% presented as…
Recommendations
Based on the assessment undertaken, and with consideration for the information
previously provided, it is recommended that:
1.
If you have any further questions please contact the undersigned on (therapist’s
number) or Manager, Nicole Grant at nicole@gatewaytherapies.com.au.
%%ASSIGNEDTO%%
Occupational Therapist
Gateway Therapies
12/02/2016
%%FULLNAME%%), Initial Occupational Therapy Assessment Report, (Insert date of report)