Occupational Therapy Treatment Plan Agreement Form
Client Information
Client Name
Date of Birth
Address
Phone Number
Diagnosis / Reason for Referral
Treatment Plan
Goals
Interventions / Strategies
Session Frequency & Duration
Expected Duration of Treatment
Informed Consent
I have discussed and agree to the proposed occupational therapy treatment plan. I understand the potential benefits, risks, and alternatives. I know I may withdraw consent at any time.
Client/Guardian Signature
Date
Therapist Signature
Date