Acute Care Occupational Therapy Referral Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Admission Date
Referring Physician
Contact Information
Diagnosis / Reason for Referral
Primary Diagnosis
Additional Diagnosis
Reason for OT Referral
Current Functional Status
Mobility/Transfers
ADLs (Activities of Daily Living)
Cognition/Communication
Precautions & Relevant Medical History
Precautions (e.g. falls, infection, weight bearing)
Relevant Medical History
OT Evaluation Needs
Areas for OT Assessment
Referring Clinician Name
Date of Referral