Consent Form Template for Occupational Therapy


Originally published – March 2021. Republished for relevance May 2024.

Welcome to part four in our series of Occupational Therapy (OT) aimed at helping you run your clinic better! We’ve talked about invoicing, intake, and Telehealth consent and we will go in-depth into Consent Form Template and Payments Templates. At the end, we’ll also provide you an Occupational Therapy consent form template to get started.

I’ll explain what to include in your consent and payment forms, why combining them is beneficial, and provide an example template that I use.

What is a consent and payment agreement form?

The consent and payment agreement form informs the patient about their care details and outlines their responsibilities within treatment and payment with you, the Occupational Therapist. This form aims to offer transparent information about your services, including how you’ll safeguard their personal health information (PHI) and procedures for sharing information with other healthcare providers.

Alongside an adult occupational therapy consent and payment form template, I’ll also provide one for children, particularly for those working in pediatrics. In Canada, if the patient is under 18, a parent or guardian must provide consent on their behalf. While the form resembles an adult’s, the language is adjusted to refer to the patient in the third person since they won’t be the ones signing it.

Why does it make sense to combine the two?

Many Occupational Therapy practitioners separate their consent and payment forms. I did this when I first started, but after running my private practice, I noticed significant overlap between the two. With so much paperwork during patient intake, I decided to combine the consent and payment forms into one to streamline the process.

What should a consent and payment agreement form for Occupational Therapy include?

Great question! Here are some things you should include in your Consent and Payment Form (and is also included in Occupational Therapy consent and payment form template below):

  1. Name and purpose of treatment: Your name, profession and the type of treatment that you will be providing to the client. 
  2. Consent for photo/video: In the event that you use video or photos to support assessment or evaluation of clients, you will need their permission, and explain how the video and photos will be used. For example, if you are setting up an environment and need to take a picture of a bathroom to remember the location of the toilet and shower heads for recommending equipment. Or, if you are assessing how a child prints and want to capture how they hold their pencil.
  3. Consent for PHI: What is PHI? Personal Health Information is health information about an individual that identifies the specific individual, examples include date and location of birth, diagnosis, weight and height, etc.
  4. Consent to sharing information with other healthcare providers: In the spirit of collaboration, you require consent from your client to share and talk with other healthcare providers that are involved in their treatment. We call this third party participation, it could be a Physiotherapist, Lawyer, Social Worker, and you would be consulting to support the big picture care of your client. 
  5. Service fees: This is what you will charge for the services you offer, whether it might be treatment, assessment, or documentation. You can choose between billing hourly (for each minute and hour you spend working on the client file, or sessional, where you charge them a higher fee for the session that includes the prep, charting, and communication in between sessions. 
  6. Right to withdraw consent: The ability to withdraw whenever is important, as the client may no longer agree with your treatment plan or methods and no longer provide consent for you to treat them. 

Fill out the form below to access the Occupational Therapy consent and payment agreement form template.

What you will notice is I have put together 4 different consent template options, a short and long form for both pediatrics and adults. Please make a copy as these are documents. Enjoy!! 

Disclaimer: This information is freely shared but not to be taken as legal advice. 


I’m a strong advocate of automation. While this Occupational Therapy consent and payment form template is a great starting point, Therabyte EMR can help you elevate your practice with workflow automation when you’re ready!




Looking forward to connecting soon, please reach out with any comments or questions at


Ashley Reina,

Occupational Therapist & Co-founder of Therabyte App


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