Client Consent Form and Contract :: Annelene Naidoo

I, the undersigned, grant Annelene Naidoo permission to treat myself or legal guard in her capacity as a clinical psychologist. I hereby give permission to the therapist to interview, assess and treat me according to the guidelines and terms mentioned below

I, the undersigned, understand and acknowledge the following.

All information will be treated as confidential. There are times where a legal or ethical obligation rests on the therapist to disclose information. It is required by law to report to the appropriate authorities any suspected, past or present, child abuse, elder abuse or abuse of people with disabilities. When a threat of bodily harm to self or others is present, the therapist will break the confidentiality of communications. This includes receiving a court order for disclosure.

With consent, relevant information may be discussed with the referring psychiatrist or other mental health professionals registered with the Health Professions Council or South African Social Work Council.

I understand that Annelene Naidoo’s consulting fees are in accordance with the Board of Healthcare Funders of South Africa. I accept that sessions are charged at medical aid rates and are subject to annual increase.

Consultation fees are payable at the end of each session via cash or EFT, unless alternative arrangements have been agreed on. This includes any and all legal costs resulting from legal action/ debt collection for overdue accounts.

Interest accrues at 1.5% on late or overdue payments.

Sessions will be ended immediately and billed for in full, should there be the presence of intoxication or influence of substances.

Appointments need to be cancelled with 24 hours notice to avoid being billed in full. The same applies to missed appointments. This fee will be waived if a doctor’s note is produced.

Should two (2) consecutive appointments be missed, the standing appointment will be cancelled going forward and will need to be rebooked.

Rescheduled appointments are subject to availability and are scheduled for the following day. Alternatively, this will be considered a cancelled/missed appointment and billed accordingly.

Patients are responsible for submitting receipts/statements for reimbursement. This practice is not responsible for failure of reimbursement from your medical aid scheme.

Psychotherapy/ assessments are purely for diagnostic and treatment purposes, and may not be used for forensic purposes.

I, the undersigned, accept full responsibility for my account and to settle any outstanding payments. Moreover, I accept full responsibility to ensure that I have received the necessary invoices for sessions that I have attended.

If my invoices are paid at private rates, I understand that it is my responsibility to make payment on the date of the therapy session. Annelene Naidoo will make available credit and debit card facilities to make this payment process possible.

The banking details are as follows:
Bank : First National Bank
Account : Annelene Naidoo
Branch Name : Northgate
Branch Code : 256755
Type of Account : Current/Cheque Account
Account Number : 62362716270
Reference : <Your Full Name>

If my invoices are being submitted to medical aid, I understand that it is my responsibility to liaise with my medical aid regarding payments due and keeping up-to-date with my available funds. If my account has not been paid for a period of 30 days or more, the full payment will be processed against the authorised bank account. If you’re a medical aid client, a payment on your account will only be processed if the medical aid has not paid the submitted invoice, and it is clearly indicated on the medical aid remittance. You will be notified of this rejection, and of the date that the payment will be processed on your account. The estimated time to get a payment from the medical aid is 4-6 weeks from the date that the invoice is submitted. With all rights reserved, Annelene Naidoo has the option to use legal methods to secure payment; this may include a collection agency or small claims court, in which case the cost of such measures will be added to the claim. Notices of outstanding accounts will be served to your residential, postal and work addresses.

I understand that Annelene Naidoo may suspend therapy until all outstanding accounts are settled in full.

I understand that if an appointment is not cancelled within 24 hour advance notice, I will be billed in full for the sesson. The debit order authorisation, as completed below, will be used to process payment against your authorised bank account. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Annelene Naidoo serve as a courtesy and have no bearing on the confirmation of an appointment.

I acknowledge that phone calls and emails that are longer than 10 minutes will be charged for.

Any sessions/consultations with third parties will be charged to the undersigned, even if at the request of Annelene Naidoo. With regard to minors, feedback sessions to parents are charged in full.

I understand that that the email address and mobile number provided by me below will be used for all correspondence related to my appointments and invoices. Should I not receive the related invoice within 5 working days after a session (those that are attended or missed), I will be responsible for ensuring that I follow-up and ensure that I do have a copy of the related invoice.

I, the undersigned, accept that any late-coming will shorten the length of my session and I will be charged in full. Sessions cannot run overtime if the client is late.

The contract terms in terms of the debit order can be found lower on this page, for your reference.

Note that the information below with a ‘*’ is mandatory. If you don’t have this information, you can enter a ‘-‘. However, if the information is missing or inaccurate, it will result in a delay of the appointment scheduling, billing process and/ or medical aid follow-up process.

Title

First Name *

Last Name *

Email *

Mobile Number *

Home Number

Work Number

ID Number *

Date of Birth *

Age

Referring Health Care Professional

Residential Address *

Residential Address Postal Code *

Postal Address

Postal Address Postal Code

Occupation

Work Company Name *

Work Telephone Number *

Work Company Address *

Person Responsible for Account – Full Name *

Person Responsible for Account – Email Address *

Person Responsible for Account – Mobile Number *

Person Responsible for Account – ID Number *

Person Responsible for Account – Home Address *

Person Responsible for Account – Home Postal Code *

Person Responsible for Account – Company Name *

Person Responsible for Account – Work Telephone Number *

Person Responsible for Account – Work Address *

Person Responsible for Account – Work Postal Code *

Emergency Contact Person – Full Name

This information will only be used in the case of an emergency

Emergency Contact Person – Email Address

This information will only be used in the case of an emergency

Emergency Contact Person – Mobile Number

This information will only be used in the case of an emergency

Relationship to Emergency Contact Person

Medical Aid Details – Medical Aid Name *

Medical Aid Details – Medical Aid Number *

Medical Aid Details – Medical Aid Plan *

Medical Aid Details – Main Member Full Name *

Medical Aid Details – Main Member ID Number *

Medical Aid Details – Dependant Full Name *

Medical Aid Details – Dependant Code *

Permission to submit diagnosis code to medical aid? *

Bank Name *

Account Holder Name *

Account Number *

Account Type *

Branch Name *

Branch Code *

I have read, understood, and agree to the terms related to the medical aid payment via debit order if the medical aid claim is rejected *

I hereby declare that the information given in this intake form is true and correct to the best of my knowledge and belief. (copy) *

CONTRACT TERMS
The following are the terms of the debit order for your reference:
This signed Authority and Mandate refers to our contract as dated as on signature hereof (“the Agreement”). I/We hereby authorise you to issue and deliver payment instructions to the bank for collection against my/our abovementioned account at my/our above mentioned bank (or any other bank or branch to which I/We may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 30 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above.

The individual payment instructions so authorised to be issued must be issued and delivered as follows:
Daily; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due;

I/We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

MANDATE
I/We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.

PRICING
As per outstanding invoices processed by Annelene Naidoo.

CANCELLATION
I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

ASSIGNMENT
I/We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.

AGREEMENT
By completing this form, you agree to the Terms of Use (available on our website), Website Privacy Policy (available on our website), and terms and conditions specified in your client intake contract with Annelene Naidoo.