Informed consent for occupational therapy evaluation and treatment covering functional goals, therapeutic activities, home program expectations, and progress reporting. Single signer (patient).
The Occupational Therapy Evaluation & Treatment Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, healthcare, occupational therapy, rehabilitation. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Occupational Therapy Evaluation & Treatment Consent > **Important — not medical advice.** For use by a licensed provider; verify state scope-of-practice and informed-consent rules. **Date:** ___________ **Practice / Clinic Name:** ___________ **Occupational Therapist (OT):** ___________ **License Number:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ --- ## 1. Purpose of Services (a) The Patient consents to an occupational therapy evaluation and, upon agreement of the resulting treatment plan, to occupational therapy services as recommended by the OT. (b) Occupational therapy promotes health, well-being, and participation in daily life activities (occupations) through therapeutic use of meaningful activities, environmental modifications, and adaptive strategies. **Referral Source:** ___________ **Reason for Referral / Primary Concerns:** ___________ --- ## 2. Areas of Evaluation The evaluation may assess any or all of the following areas: **Activities of Daily Living (ADLs)** (bathing, dressing, grooming, feeding, toileting): ___________ **Instrumental ADLs** (home management, meal preparation, finances, medication management): ___________ **Fine Motor and Hand Skills** (grip strength, dexterity, coordination, handwriting): ___________