Healthcare Seasonal Therapy Form

Healthcare Seasonal Therapy Form

Purpose: This form documents patient information, clinical background, informed consent and authorizations specific to participation in a seasonal therapy program. Completion of this form is required prior to initiation of services. Patient consents below are voluntary and may be withdrawn in writing except where clinical safety or legal obligations require otherwise.

Patient Information

Female Male Non-binary Prefer not to say

Emergency Contact

Insurance Information

Medical History

Seasonal Therapy Program Details

Check all therapy modalities included in this seasonal program:

Light therapy (phototherapy) Cognitive behavioral therapy (CBT) Exposure-based therapy Physical therapy interventions Occupational therapy Group therapy Telehealth sessions Other (describe below)

Program Start Date:     End Date:

Risks, Benefits, and Acknowledgements

I acknowledge that seasonal therapy has potential benefits, including symptom reduction and improved functioning, and potential risks, including transient increases in distress, mood variation, eye strain (for light therapy), and the need for medication or treatment adjustments. Alternative treatment options have been discussed. I understand no specific outcome is guaranteed.

I understand I may withdraw consent or discontinue therapy at any time without jeopardizing future care. Withdrawal must be communicated in writing or documented in the clinical record. In emergencies the provider may implement safety measures or contact emergency services.

Confidentiality: Except as required by law, information disclosed during therapy is private. Exceptions include mandatory reporting of child/elder abuse, reasonable suspicion of imminent harm to self or others, and court-ordered disclosures.

Patient agrees to notify the provider of medication changes, worsening symptoms, or new medical issues that could affect participation in seasonal therapy.

I have read and understood the Risks, Benefits, Confidentiality provisions and Acknowledgements above.

HIPAA Authorization & Privacy Acknowledgement

By signing below I authorize the release and use of my protected health information for treatment, payment and healthcare operations as necessary for the delivery of seasonal therapy services. I acknowledge receipt of the practice's Notice of Privacy Practices and understand my rights regarding access, amendment and accounting of disclosures to the extent allowed by law.

I acknowledge receipt of the Notice of Privacy Practices and authorize use/disclosure for treatment, payment and operations.

Authorization Expiration Date:     If no date is provided, this authorization expires 12 months from the date of signature below.

Billing, Cancellation & Communication Policies

Patient is responsible for fees for services rendered. When billing insurance, patient understands claims will include clinical diagnosis codes and necessary clinical information. Cancellation policy: appointments cancelled with less than 24 hours' notice may be subject to a cancellation fee.

I authorize billing to my insurance and assignment of benefits for covered services.

I authorize the provider to maintain my signature on file for billing purposes.

Communication preferences: I consent to appointment reminders and treatment communications via the contact methods I have provided, understanding standard text/email/SMS risks to privacy.

I consent to receive appointment reminders via phone, text or email.

Additional Consents

I consent to receive all or part of my seasonal therapy via telehealth when clinically appropriate and accept related risks.

I consent to photography or audio/video recording for clinical documentation only (if applicable). I understand recordings are protected and will not be used for other purposes without separate consent.

Certification

By signing below I certify that the information provided is accurate to the best of my knowledge, I understand the treatment plan, risks and alternatives described above, and I consent to the provision of seasonal therapy services consistent with this form.

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