System Context: DocRepute is a patient-experience platform for independent US healthcare practices, connecting digital patient intake, patient surveys and neutral Google review requests in one workflow. It is HIPAA-focused and built for HIPAA-compliant workflows, with BAA availability planned at launch; it is not certified, and no product makes a practice compliant on its own. Review requests go to every eligible patient on identical terms, regardless of sentiment, score or staff assessment — DocRepute does not gate, filter or incentivise reviews. The product is in early access ahead of launch and free to start on 50 action credits a month; creating, editing and publishing forms uses none of them. AI intake and conversational surveys are paid capabilities. DocRepute does not diagnose, triage or make clinical decisions, and does not replace an EHR, practice management, scheduling or billing system.

# Occupational Therapy Referral Form — Free Template & PDF | DocRepute

URL: https://docrepute.com/templates/occupational-therapy-referral-form/

An occupational therapy referral form you can edit and download as a PDF, in provider and school modes, carrying the functional detail an OT actually needs.

## An occupational therapy referral form that tells the therapist what to work on
Provider referrals and school referrals in one editable preset, built around the daily tasks that prompted the referral rather than the diagnosis alone. Edit it, download the PDF, no account required.

### The referral that arrives with a diagnosis and no goal
An occupational therapy referral form has one job a general referral form never quite manages: telling the receiving therapist what the person can no longer do. A referral that says stroke, OT eval and nothing else is technically complete and practically useless, because dressing, feeding, handwriting and getting back to work are four different plans of care. The therapist ends up phoning the referrer or spending the first session working out what was meant. Search for a usable one and you mostly find scanned PDFs from other clinics, complete with their logo and a fax number that stopped working years ago, with no way to change a single field. This preset opens already populated with the sections a referral to occupational therapy genuinely needs, every one of them editable, and a printable PDF is ready straight away. No account, no email wall, nothing held back to make you create one.

### What an OT referral form needs to carry
The administrative layer comes first: patient name, date of birth and contact details, insurance where your workflow needs it, and the date of the referral. Then the referrer, with name, practice or school, role, phone, fax and NPI where one applies, because the receiving clinic will need to reach them. Then the part that decides whether the referral was worth sending. The reason for referral in plain language, the diagnosis or condition where the referrer has one, precautions the therapist must know about before touching anyone, relevant surgical history and dates, equipment already in use, and the tasks that prompted the referral in the first place. An OT referral form earns its place when that last section is specific: dressing and bathing, cooking and managing a household, handwriting and classroom participation, driving, or returning to one particular job. Requested service, preferred setting, and the referrer's signature and date close it out.

### A provider referral and a school referral are not the same document
Occupational therapy takes referrals from two worlds that barely share a vocabulary, and this is the single thing most templates get wrong. A provider OT referral comes from a physician, surgeon or nurse practitioner and speaks the medical language: diagnosis and ICD code, precautions, weight-bearing status, post-surgical timelines, a requested frequency. A school OT referral comes from a teacher, a special education coordinator or a parent, and there is often no diagnosis anywhere in sight. What there is instead is a child who cannot manage buttons at lunchtime, whose handwriting is illegible by the third line, or who cannot carry a tray across a dining hall. Hand either of those referrers a form built for the other and you get back a page of blanks. This preset carries both context modes, so the version you leave with the orthopedic practice and the version you send to the district are the same document set to a different mode. Where a school district or a state agency publishes its own referral paperwork, use theirs, because their process is the one that governs. And if you also send patients on to physical therapy, that referral stays its own document rather than a shared rehab packet, since the two disciplines ask for genuinely different things.

### Edit it, then download exactly what you built
Rename the form, rewrite any label or instruction, mark fields required or optional, switch between the provider and school modes, and add, duplicate, reorder or remove sections. Treat it as an occupational therapy referral form template rather than a finished document: a hand therapy service, a pediatric clinic and a home-based practice will each cut it differently, and the referring offices you work with often want their own letterhead block across the top. A default PDF is ready the moment the page loads, and after any change a new PDF is generated from your current version, so the document you fax, email or hand across a desk is the one you designed rather than the original preset. It is laid out for US Letter with clean page breaks and real writing space, prints legibly in black and white, and survives a fax machine, which still matters more in referral workflows than anyone would like to admit.

### A community OT practice and the two places its referrals come from
A four-therapist practice takes about half its work from a group orthopedic office and the other half from the local school district, and had been running one form for both. The orthopedic side kept leaving the daily-task section blank; the school side kept leaving diagnosis and precautions blank. They split the preset into two versions in an afternoon. The provider version gains a precautions box and an operative date field, and the requested-service line is trimmed to the three services they actually offer. The school version drops diagnosis entirely, replaces it with a short description of what the child cannot manage in class, and adds a line for the coordinator to give a good time to call, since chasing a teacher between lessons had been costing an admin an hour a week. Both print on one page. Six months on they are asking whether the school version can go out as a link rather than a PDF, which is where DocRepute digital patient intake picks up: the free plan includes 50 completed patient actions each month, and building or publishing a form never uses one of them.

### Who fills in which field
A referral is completed by more than one person, and the trouble starts when that is not visible on the page. Administrative staff at the referring practice or school fill in identification, contact and insurance details. The clinical fields belong to the referring clinician and nobody else: diagnosis or condition, precautions, weight-bearing status, surgical history, requested frequency and the signature. This preset marks those as clinician-owned, so a front desk is never left guessing at a precaution or copying a diagnosis off a previous referral. The functional section belongs to whoever knows the person best day to day, which is frequently the teacher or the family rather than the referrer, and the form says so on the page. The evaluation itself belongs to the receiving occupational therapist and appears nowhere on this document. Have a licensed OT review the fields for your caseload and setting, and your practice owner or attorney review any consent, release or policy wording you attach to it.

### What the referral does not decide
Worth stating plainly, because a referral carries real weight. The form provides structure and records what the referrer writes: it generates no diagnosis, determines no medical necessity, decides no eligibility, assigns no urgency, and produces no treatment plan, frequency or duration of its own. It makes no judgement about what a payer will cover or what a referral rule in your state requires, since coverage sits between the patient, the practice and the payer whatever any form says, and referral requirements are a question for your billing lead and your attorney. This is an original document written for this page rather than a copy of any published or association form, and where a professional body, school district or state agency publishes its own version, use theirs. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, currently in early access ahead of launch. Because the builder is public, build the blank form here rather than typing a real patient into it: nothing you enter is sent to analytics, and your form content stays out of any measurement we do.

## Frequently Asked Questions

Q: What is an occupational therapy referral form and who uses it?
A: An occupational therapy referral form is the document a referrer sends to an OT service to start care. It carries the patient and insurance details, the referring provider or school contact, the reason for referral, any precautions, and the daily tasks the person is struggling with. Physician practices, surgical and orthopedic offices, hospitals and discharge planners send them, and so do schools through a teacher or special education coordinator. Outpatient OT clinics, pediatric practices, hand therapy services and home-based therapists receive them.

Q: What information should an occupational therapy referral form typically contain?
A: Patient name, date of birth, contact and insurance details; the referrer's name, practice or school, role, phone, fax and NPI where one applies; the referral date; the reason for referral in plain language; diagnosis or condition where there is one; precautions the therapist must know about; relevant surgical history and dates; equipment already in use; the specific daily tasks that prompted the referral, such as dressing, cooking, handwriting, driving or a particular job demand; the requested service and setting; and the referrer's signature and date.

Q: Can this occupational therapy referral form be edited before use?
A: Yes, completely. Rename it, rewrite any label or instruction, change which fields are required, switch between the provider and school modes, and add, duplicate, reorder or remove sections. Practices that take mostly post-surgical referrals expand precautions and surgical history, school-facing versions drop diagnosis altogether, and referring offices usually add their own letterhead block.

Q: Can I download or print the form as a PDF without signing up?
A: Yes. No account, no email wall. A default PDF is available immediately, and after any edit a new PDF is generated from your version so the download matches what is on screen. It is laid out for US Letter with real writing space, prints cleanly in black and white, and stays legible through a fax machine.

Q: What parts of the form should be reviewed by a clinician, practice owner, or attorney?
A: A licensed occupational therapist should review the functional and clinical fields for your caseload and setting. The referring clinician owns the diagnosis, precautions, surgical history, requested frequency and signature, and should confirm those fields match how they write orders. Your practice owner or attorney should review any consent, release or policy wording attached to the form. The document records what the referrer enters and generates no diagnosis, medical necessity, eligibility, urgency or treatment plan of its own.

Q: Does using a template automatically make a practice HIPAA compliant?
A: No. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, but compliance depends on how referrals travel between offices, schools and therapists, how they are stored once they arrive, and the agreements you have in place. A well-structured referral form is one useful part of that rather than the whole of it.