Request an Occupational Therapy Assessment

Occupational Therapy Assessment
Who is the assessment for?


Referrer details
Title




Who shall we contact if we need to do a telephone assessment?



Title




Service user
Title




Address
 

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Gender




Medical or health conditions
Property details
Is your property a




Is your property




Do you live



Reason for contact
Tell us what you need help with







Stairs
Can you climb stairs independently?


Bathing
Does your bathroom have



Do you have any adaptations (for example bath lift, bath board, swivel bather etc)?


Can you stand when in the shower?


Do you have hand rails around the bath/shower?


Access to property
Are there steps to access the property?


Can you exit the property independently?


Do you use any equipment / adaptations to exit the property?


Toileting
Can you use the toilet without help?


Do you use any equipment / adaptations when toileting?


Do you have incontinence problems?


Kitchen tasks
Do you cook for yourself?


Do you make your own hot drinks?


Do you walk with a walking aid?


Bed or chair tasks
Can you get in/out of your chair without help?


Do you use any equipment / adaptations to help you transfer from a chair?


Do you have any pain when sat in chair?


Do you sit in your chair 3 hours or more?


Can you get in/out of bed without help?


Do you use any equipment / adaptations to help you transfer to/from bed?


Do you have any pain when laying in bed?


Mobility
Do you have a wheelchair?


Can you walk independently?


Do you use walking aids?


Additional information
Occasionally the OT may use technology such as Skype, WhatsApp etc as part of the assessment process. Do you have access to this technology? - optional


Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page