Healthcare Postpartum Therapy Form

HEALTHCARE POSTPARTUM THERAPY FORM

Purpose: This form documents the patient’s medical, obstetric, and psychosocial history relevant to postpartum therapy services (including pelvic floor physical therapy, lactation support, mental health interventions, and related rehabilitative care), records informed consent, and authorizes limited exchange of information for treatment and billing as described below.

Patient Information

Patient Name:

Date of Birth:   Gender:

Emergency Contact

Insurance Information

Pregnancy and Delivery Details

Date of Delivery:   Hospital/Facility:

Attending Provider:   Gestational Age (weeks):

Vaginal    Cesarean section    VBAC    Assisted (forceps/vacuum)

Postpartum Symptoms and Current Concerns

Pelvic or perineal pain    Excessive bleeding    Signs of infection (fever, drainage)   
Urinary incontinence or urgency    Bowel dysfunction    Breastfeeding/lactation difficulties   
Sleep disturbance    Mood changes, anxiety, or depression    Pain with sexual activity

Medical History

Mental Health Screening

Over the past two weeks, have you experienced:
Little interest or pleasure in doing things    Feeling down, depressed, or hopeless   
Excessive worry or anxiety    Panic attacks or severe anxiety   
Thoughts of harming self or baby (if checked, clinician will address immediately)

Therapy Goals and Preferences

Yes    No

Consent for Treatment, Confidentiality, and Billing Authorization

I hereby consent to receive postpartum therapy services recommended by my clinician, which may include physical therapy focused on the pelvic floor, musculoskeletal rehabilitation, lactation support, and brief mental health assessment and interventions. I understand that benefits of therapy include pain reduction, improved function, enhanced breastfeeding support, and improved mood and coping. Risks may include temporary increased soreness, fatigue, or discomfort. No guarantee of specific clinical outcomes is provided.

I understand that my protected health information (PHI) will be treated as confidential except as required or permitted by law, including mandatory reporting for risk of harm to self or others, suspected abuse of a minor or vulnerable adult, or as required by court order. I authorize the release of records to other treating providers and to my insurer as necessary for treatment, payment, and healthcare operations related to postpartum therapy.

I understand I may withdraw this consent in writing at any time, except to the extent that action has already been taken in reliance on this consent. Withdrawing consent will not affect actions already taken. I acknowledge my right to ask questions and to receive explanations about recommended treatment, alternative options, and estimated costs.

I authorize the clinic to submit claims to my insurance and to obtain payment from my insurer for postpartum therapy services.

I authorize release of relevant medical information to my other treating providers for continuity of care.

Patient Acknowledgements

I acknowledge that I have provided a complete and accurate history to the best of my knowledge, that I understand the nature of the postpartum therapy services to be provided, and that I have had the opportunity to ask questions. I understand that if I experience thoughts of harming myself or my baby, I should notify my clinician or seek emergency care immediately.

Permission to leave voicemail or appointment reminders: Yes    No

Provider Notes (For Clinical Use)

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