Consent for Treatment

I am requesting an evaluation with Bloom Therapy Co. for myself or my child.  This evaluation will include but not be limited to medical history, current concerns, visual and manual assessment as applicable.

Client Responsibility

I understand that my physician is my primary health care care provider and that he/she is responsible for my overall care.

I understand that Sheridan Seitz, as an occupational therapist, is an allied health care provider and is responsible for evaluating and recommending a care plan. All clients are provided with a written and/or verbal care plan to address relevant concerns. The client and the occupational therapist each have responsibilities in this plan. I understand resolution of many concerns often take several days or weeks and may require a change in the original recommended care plan at some point.

I understand any instructions or recommendations given may be discussed with my or my child's health care providers. 

I understand that I am responsible for informing the occupational therapist of changes I feel are necessary in the care plan at the time of the visit or during the course of follow-up communication. I understand it is my responsibility to communicate progress, questions or concerns.

Confidentiality

I understand that it is my choice whether or not to have someone else present during the visit, and that anyone who is present during the visit will have access to my healthcare information and my confidentiality may not be guaranteed. If I have requested an in-home appointment, I understand that GPS will be used to navigate to my home.

COVID-19 Waiver of Liability

 Clients should monitor symptoms to ensure all who live in the home are symptom-free (fever, cough, respiratory distress, etc). Client releases Bloom Therapy Co.  from any and all liability related to the visit. This release includes any claims whether a COVID-19 infection occurs before, during, or after participation in a session.'

ADMINISTRATIVE POLICIES

Financial Responsibility

Bloom Therapy Co. requires a refundable deposit for appointment confirmation and remaining balance paid at the time of each service. Acceptable forms of payment include: debit/credit cards and HSA/FSA cards. Payment link will be sent prior to first appointment for you to submit a $50 deposit in order to secure your time slot. The link will be sent via text to the phone number provided on your intake form. Please pay your deposit within 24 hours of receiving the link in order for your appointment to be confirmed. If your deposit is not received within 24 hours, your appointment time will be released and available for another client to book. At time of service, your remaining balance will be charged to the card you provided. 

All fees are subject to change by the therapist at any time. Travel fees may apply for home visits.

Insurance Information

Bloom Therapy Co. does not bill insurance companies directly. Obtaining reimbursement from the insurance company for services, including lactation and bodywork sessions, is ultimately the responsibility of the client. Reimbursement is not guaranteed and will depend on the individual insurance policy. Bloom Therapy Co.  will provide assistance, within reason of their sole discretion, to client by providing copies of necessary documents such as invoices or proof of treatment.

Cancellation

If needing to cancel or reschedule, this must be communicated at least 24 hours before the appointment time. Timely rescheduling requests will allow your deposit to be transferred to a future date. Timely cancellation will result in a full refund of your deposit. Cancellation/reschedule requests less than 24 hours before the appointment will result in loss of your $50 deposit as we are unable to rebook this time slot. No show without any prior communication will result in charge of your full session fee. Cancellation fees are not eligible for insurance reimbursement. Arriving more than 15 minutes late for a scheduled in-person or virtual appointment may result in cancellation depending on therapist’s discretion and availability.

Communication

Text and email are not secure forms of communication. If choosing to communicate through these mediums, your therapist will respond through that medium.

Any third party included on any email, text, or other communication is granting permission for Bloom Therapy Co. to communicate my protected health information and/or that of my children  with that third party. Bloom Therapy Co. will not initiate inclusion of any third party on an email or text.  I acknowledge that Bloom Therapy Co. is not responsible for any breach of confidentiality made by any person I invite to be present during a visit, or added by me as a third party to text, email or other modes of communication.