Occupational Therapy Services Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Occupational Therapy Services

Nature of Services

I, _________________________, hereby consent to receive occupational therapy services from [Practice Name]. I understand these services may include:

• Evaluation and assessment procedures
• Treatment interventions and activities
• Home exercise programs
• Adaptive equipment recommendations
• Environmental modification suggestions

Risks and Benefits

I understand that occupational therapy may involve:

Potential Benefits:

• Improved functional independence
• Enhanced daily living skills
• Better quality of life
• Increased participation in meaningful activities

Potential Risks:

• Temporary soreness or discomfort
• Potential for minor injury during therapeutic activities
• Possible emotional responses to therapy

Financial Responsibility

I understand that I am responsible for:

• Payment of all charges not covered by insurance
• Obtaining necessary referrals and authorizations
• Informing the practice of insurance changes

Privacy Notice

I acknowledge receipt of the Notice of Privacy Practices and understand how my health information may be used and disclosed.

Right to Refuse Treatment

I understand that I have the right to:

• Refuse any treatment procedure
• Ask questions about proposed interventions
• Withdraw consent at any time

Signatures

Patient/Guardian Signature: _________________ Date: _________

Occupational Therapist: ____________________ Date: _________

Witness: _________________________________ Date: _________

Contact Information

Practice Phone: _______________ Emergency Contact: ___________