OT functional assessment report template

An OT functional assessment report documents a client's functional capacity across six occupational domains: self-care, productivity, leisure, motor, cognitive and environmental. It uses standardised outcome measures (for example FES-I for falls concern, Berg Balance Scale for balance, DASS-21 for mental health) to establish baselines, track progress across sessions, and provide evidence-based recommendations to GPs, referrers, insurers and NDIS planners. The report typically includes scored assessments, severity classifications, trend analysis, functional domain observations, client goals, clinical reasoning, an intervention plan and recommendations.

Yes. You can download a free sample OT assessment report as a PDF with no email required: a realistic falls prevention case with FES-I and Berg Balance Scale scores, severity bands, functional domain mapping and clinical narrative across all 10 report sections. For a fully editable blank Word template pre-structured with all report sections, enter your email above and we'll send it straight to your inbox. To create reports from your own scored assessment data, start a free ClientForms account.

An OT report should include: client information and referral background, the standardised outcome measures administered with their scores and severity bands, functional capacity findings across the relevant domains, the client's goals and progress against them, clinical reasoning that links assessment scores to the functional presentation, an intervention plan, and clear recommendations for the referrer, insurer or NDIS planner. Reports written for different audiences emphasise different sections: a progress report leads with change over time, an insurance report leads with functional capacity and prognosis.

Start by selecting standardised outcome measures relevant to your client's goals: FES-I and Berg Balance Scale for a falls prevention case, ARAT and FMA-UE for upper limb rehabilitation, or K10 and DASS-21 for mental health. Administer assessments at baseline and regular intervals to establish a measurable trajectory. Structure your report around client information and referral background, assessment scores with severity bands, functional capacity across six domains, client goals and progress, clinical reasoning linking scores to functional presentation, an intervention plan, and recommendations. ClientForms handles the scoring, severity classification and trend tracking; you focus on clinical observations and reasoning.

Six functional domains: self-care (personal ADLs such as showering, dressing, meal preparation), productivity (work, education, home management), leisure (social and recreational participation), motor (balance, mobility, upper limb function, coordination), cognitive (executive function, memory, attention) and environmental (home safety, equipment needs, accessibility modifications). Each domain includes score-driven hints based on your assessment results, plus space for your clinical observations.

ClientForms includes 30+ OT outcome measures across seven categories: FES-I, BBS, ABC, Tinetti and LEFS for falls and balance; ARAT, CAHAI, FMA-UE, PROMIS-UE, PRWHE and GAS for upper limb and motor; NEADL, SCIM-III, RNLI, CIQ and PROMIS-PF for daily living; K10, PHQ-9, GAD-7, DASS-21, CORE-10 and ISI for mental health; NPRS, PCS, TSK-11, GSE and FSS for pain and self-efficacy; WHO-5, WEMWBS and SSQOL-12 for quality of life; SDQ and DCDQ for paediatric assessments. All are scored with severity bands and clinical thresholds.

When you administer assessments through ClientForms, scores are calculated with severity bands and clinical thresholds (for example FES-I scores are classified as Low, Moderate or High Concern). When you create a report, these scores, along with trend data across sessions and Reliable Change Index calculations, are pre-filled into the document. Sections clearly marked as auto-filled show what the platform calculates; you add the clinical observations, goals and recommendations that require your professional judgement.

Yes. The report downloads as an editable .docx Word document, compatible with Microsoft Word, Google Docs and LibreOffice. Pre-filled sections (assessment scores, severity bands, trend data, embedded charts) are already populated. You add your clinical narrative, functional observations, goals, intervention plan and recommendations. Save as PDF when ready to send to GPs, referrers or insurers.

The OT functional assessment report is a 10-section clinical document for GPs, referrers and insurers, focused on functional capacity across six occupational domains with outcome scores and clinical reasoning. The NDIS progress report is a 12-section document specifically structured for NDIA plan review submission with Section 34 compliance, funding line item codes and NDIS functional domain mapping. Both reports can be created from the same assessment data in ClientForms.

Three modes: Initial Assessment (baseline snapshot establishing current functional levels, used at first appointment), Progress Review (full trend analysis with Reliable Change Index, embedded charts and domain mapping, the most common mode, used at reassessment intervals), and Discharge Summary (intake vs discharge comparison with goals achieved and recommendations for ongoing self-management or community supports).

Yes. The OT report provides standardised outcome data that NDIS planners and support coordinators require: severity classifications, functional impact evidence, and measurable progress with Reliable Change Index calculations showing statistically significant change. For formal NDIS plan reviews requiring 12-section reports with Section 34 compliance, use the dedicated NDIS progress report template, created from the same assessment data.

An OT report for NDIS evidence should include: standardised outcome measures with severity classifications (for example FES-I showing High Concern for falls), functional impact across NDIS domains, measurable progress with baseline-to-current comparisons, Reliable Change Index calculations to demonstrate statistically significant improvement, client goals with progress ratings, clinical reasoning linking assessment data to functional presentation, and specific recommendations for continued support. ClientForms structures all of this into the report template, with scores and severity bands pre-filled from your administered assessments.

Every new account gets 30 days of full Professional access with no card, starting when you send your first assessment. After the trial: Free, Starter at $9/month, or Professional at $19/month, all monthly. Report export as a Word document is included with the paid plans, Professional makes every OT outcome measure available, and intake and consent forms are free on every plan.