September 29, 2026September 29, 2026 by Michel Moninger, COTA/L

How to Write an Occupational Profile in OT (With Example and Free Template)

Writing an occupational profile can feel daunting and overwhelming at first glance. With so many different aspects to be completed and a variety of areas to be covered, it is easy to feel like gathering all of this information in one session might be an impossible task.

Thankfully, AOTA has developed a free occupational profile template to help us put together a comprehensive report on someone’s occupational history in a sequential and easy-to-understand fashion. That profile template can be found here. We will be sharing an occupational profile example using this template at the end of the article.

Additionally, references in the template to the Occupational Therapy Practice Framework (OTPF) are essential in understanding key terms. Even if you have been practicing occupational therapy for many years, it is always good to refresh your understanding of our framework for each setting you work in.

According to CPT evaluation coding, an occupational profile needs to be completed as part of an occupational therapy evaluation in order for it to be billed. Of course, they do not mandate that any specific template be followed. Instead, the objective is just to make sure that an occupational therapy evaluation captures the essence of who the person is, what they want to accomplish, and what it will take to get them there.

Even still, an occupational profile is an essential tool for both the occupational therapist and occupational therapy assistant. During the course of treatment, OT practitioners will no doubt be able to have a greater understanding of certain aspects of the occupational profile. Therefore, it is essential that all occupational therapy practitioners keep these occupational profile sections in mind during treatment to ensure that appropriate and meaningful therapy is provided.

Where the Occupational Profile Fits in the OT Evaluation

It helps to remember that the occupational profile isn’t the whole evaluation–it’s one of two halves.

Under the OTPF-4, the occupational therapy evaluation consists of the occupational profile and the analysis of occupational performance. The occupational profile is where we learn who this person is: their history, their roles, what matters to them, and what they want to be able to do. The analysis of occupational performance is where we observe them in action, administer assessments, and identify what’s supporting or getting in the way.

Think of it this way: the occupational profile tells you where the client wants to go, and the analysis of occupational performance tells you what’s standing between them and getting there. You need both. A profile without the analysis leaves you with meaningful goals and no plan to reach them. An analysis without the profile leaves you with a list of deficits and no reason any of them matter to the person in front of you.

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Looking through the 23 blanks to be filled in, the occupational profile can be further broken down into 5 major sections for us to discuss:

Client report
Contexts
Performance patterns
Client factors
Client goals

We will go through each of these in detail to help you write your occupational profile.

1. Client Report: Starting the Occupational Profile Interview

The client report is the most fundamental and straightforward section of the occupational profile. Essentially, the client report is just the results of a brief interview to find out the patient’s history. Obviously, the specific questions you will ask will vary greatly based on your treatment setting.

It could include questions like:

Why are you seeking occupational therapy services?
What current and past illnesses and deficits have you faced?
What challenges are you facing in your daily routine?
What do you think you do well? What do you want to be able to do well?
What do you do for work?
What do you do for fun?
What do you consider to be independence?

Typically, some of these questions can be answered prior to the in-person evaluation through a written occupational therapy screening report. Other times, things like diagnostic codes and medical charts will answer these for you.

Regardless, having a personal interview is an invaluable tool to keep your occupational profile and occupational therapy treatments client specific and occupation-driven.

2. Contexts: Environmental Factors and Personal Factors

Now that we understand the person a little bit better, we can zoom out and see the contexts that the person lives in. This will include two distinct types of contexts, environmental and personal. A good way to remember the difference between environmental and personal contexts is that environmental context are the circumstances surrounding the individual, but personal context is the circumstance within the individual.

Here are some example questions that can be asked to ascertain environmental contexts:

Where do you live?
Who lives with you?
What kind of adaptive equipment or home modifications do you have?
Does someone come in to help you with anything?
What kind of modifications have been made at your workplace?
How often do you receive therapy and other services?

On the other hand, these are some questions that can help you identify personal factors:

How old are you?
What cultures and communities do you identify yourself with?
Where did you grow up?
Have you had any family members with similar challenges that you are facing?
Where did you go to school?
Who do you like to spend time with?

As you might notice, personal context questions can be a bit, well, personal. This is where an occupational therapy practitioner’s therapeutic use of self will really come into play. Some aspects of the occupational profile may not be completed right away as your relationship with the client grows over time. As your client comes to trust you and see the value of opening up to their therapist, no doubt more and more information will come to the surface that will help you paint a clearer picture.

3. Performance Patterns: Habits, Routines, Roles, and Rituals

Generally, during an interview session getting to know the client, they will have no problem answering most of the above questions. Once we get into the performance patterns section, though, it is not uncommon for the truth to be stretched. Here, we are looking at habits and routines that help or hinder in the completion of occupations. Pay close attention, because many many times people will say one thing, but then demonstrate another. In addition to looking for patterns, ask things like:

What are your habits?
What habits have you had in the past?
What patterns have you noticed in your life?
What is a day in your life like?
What roles do you fill in an average day?
What rituals do you follow?

4. Client Factors: Values, Beliefs, Body Functions, and Body Structures

Relevant client factors will vary greatly depending on the circumstances that lead a person to receive OT services. When assessing factors, remember to look out for both factors that support and inhibit engagement. This will include things like values, beliefs, and spirituality.

It is important to remove yourself from the situation during this section of the occupational profile. It can be difficult to assess someone else’s spiritual beliefs without considering them from the perspective of your own beliefs.

Good questions for this section might include:

What is important to you?
What kind of a person do you think you are?
What kind of person do you want to be?
What brings your life meaning?

Next, we look at their body functions. This includes physical function and dysfunction, mental facilities, sensation, and organ function. While some of this information will come from an interview, observation and chart review will be vital for obtaining accurate information.

Ask questions like:

What challenges do you have with movement?
What movements and functions are you comfortable with?
Are your senses affected?

Finally in this section, we look at body structures. Most of this information will likely come from questions asked earlier or from a medical history and chart review. As OT practitioners, we are intimately familiar with how the structures of the body interact and can cause facilitate or inhibit functional performance.

5. Client Goals: Making the Occupational Profile Actionable

As you’ve listened to the client give their answers, no doubt you have begun formulating goals and treatment ideas that you plan to use. Using the occupational profile, though, you can ensure that your treatments stay occupation-based and client-specific.

Here are some questions to ask:

What are your goals?
What do you want to be able to do?
What will help you maintain those goals?
How will you know that you have met those goals?

Now we know how to obtain the information, but what does this look like in practice? Below we’re sharing an example of an occupational profile filled out for a fictional patient. Our patient is a 68 year old female named Jane Smith, coming for OT services after a right-sided stroke. After reviewing this information, we know everything we need to know about this woman and are ready to get to work!

By keeping an occupational profile in mind during both OT evaluations and treatments, we can make sure that our treatments are meaningful to the client and effective within the OT scope of practice.