Occupational Therapy Home Visit Template
Client Name
Date of Visit
Therapist Name
Referral & Reason for Visit
Referral Source
Reason for Home Visit
Client Information
Diagnosis
Age
Contact Number
Other Relevant Medical Information
Home Environment
Type of Residence
Accessibility (ramps, elevators, etc.)
Home Safety Issues
People Living with Client
Functional Assessment
Mobility Around Home
Transfers (bed, chair, toilet, etc.)
Activities of Daily Living (ADLs)
Instrumental Activities of Daily Living (IADLs)
Equipment & Adaptations
Current Equipment Used
Recommendations for Equipment/Adaptations
Goals & Recommendations
Client & Family Goals
Therapist Recommendations
Summary & Plan
Summary of Findings
Follow-Up Actions / Referrals
Signature
Date