INFORMED CONSENT CONTRACT
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them in your first session. When you sign this document, it will represent an agreement between us.
I the undersigned, grant Ashton Robertson permission to treat me in any manner as she may deem necessary in the circumstances in her capacity as a clinical psychologist.
I, the undersigned, understand that Ashton Robertson is a Clinical Psychologist & is registered with the Health Professions Council of South Africa. Ashton Robertson will explain the therapeutic process to me & I understand that I have the right to withdraw at any time.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
Please note that I do not do assessments or reports for legal purposes and you waive any ability you would otherwise have had to call on me to do so.
Scheduled sessions begin at the appointed time and for exactly 50 minutes. Sessions are usually once a week, at a time we agree upon, although depending on your request and needs, some sessions may be more or less frequent.
You accept responsibility that appointments are taken as confirmed at the time of the scheduled booking (via whatsapp/SMS/email/telephonic call/online booking). Any reminders from Ashton Robertson serve as a courtesy & have no bearing on the confirmation of an appointment.
Any late-coming will shorten the session and the session will be charged in full. Sessions cannot run overtime if you are late as this will impact the client scheduled after you.
Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 advance notice of cancellation [please see 24 hour cancellation policy attached]. If you or I believe that I am not the right therapist for you, I will give you referrals to other trusted practitioners whom I believe are suited to help you.
BOOKING OF SESSIONS
Sessions can be scheduled during the psychotherapy consult.
Alternatively, you can book online using my website: www.therapywithashton.co.za
By using the online session booking system you will be able to see what session times I have available and you can book according to what suits your schedule and mine. Once booked, this will link to my diary and you will receive a confirmatory email that your session has been booked.
24 HOUR CANCELLATION POLICY
Cancellation contact number: 074 233 3131
Please note that you will be charged in full for your session if you cancel with less than 24 hours’ notice.
This 24 hour cancellation policy is standard in the medical and mental health fields and will be strictly enforced. The reason for this policy is that 24 hours’ notice is required as advance warning as it enables me the opportunity to schedule someone else for that time. This is important because others may be on a waiting list or may be looking for an opportunity to use that session slot.
A missed session will be billed as such and not all medical aids will cover a missed session. Thus, you are accepting responsibility that a missed session will be billed in full and may (depending on your medical aid) be for you own personal account. You also accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Ashton Robertson serve as a courtesy & have no bearing on the confirmation of an appointment.
As much advance notice as possible is appreciated.
LATE ARRIVAL POLICY
Late arrival contact number: 074 233 3131
Please note that you need to notify me if you will be late for your appointment, then your appointment will be held for you and you can use the remaining time within that 50 minute slot.
If you do not notify me of your late arrival, I will wait 15 minutes, after which I will assume that you are not coming and may leave the office, especially if this is the last session slot of the day. In such a case, you will be charged in full for a missed appointment.
I am contracted to all medical aids at medical aid rates and I can claim directly on your behalf.
My cash fee for 2021 is R1060.00 per session.
If we meet for more than the usual allocated 50 minute time, I will charge accordingly. In addition to weekly appointments, I charge this same session rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour.
Other professional services include: PMB applications, referral letters, sick notes, telephonic conversations lasting longer than 10 minutes, attendance at meetings or telephonic consults with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me.
Any sessions/consultations with third parties which are reasonably necessary as part of your treatment will be charged to you, even if at the request of Ashton Robertson. With regard to minors, feedback sessions to parents are charged in full.
BILLING AND PAYMENTS
Medical aid clients: My accounts department will submit your session invoice directly to your medical aid and send you a copy for your records.
Private cash clients: You will receive an invoice from my accounts department that you will be required to pay via EFT. Alternatively, you can pay cash in hand at your session.
As the undersigned, you are accepting full responsibility for my account & to settle any outstanding payments.
Please note that fees are subject to annual increase.
If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs and my billable time lost to this process will be included in the claim.] In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due.
MEDICAL AID REIMBURSEMENT AND PRESCRIBED MINIMUM BENEFITS (PMB)
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a medical aid policy, it will usually provide some coverage for mental health treatment, usually making use of your medical aid savings. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your medical aid company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your medical aid policy covers.
You should carefully read the section in your medical aid coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your medical aid company. Due to the rising costs of health care, medical aid benefits have increasingly become more complex.
It is sometimes difficult to determine exactly how much mental health coverage is available. “Prescribed Minimum Benefit (PMB)” plans often require authorization before they provide reimbursement for mental health services. Please note, if you make use of a PMB, you are swapping inpatient care for outpatient therapy. Thus, you may forfeit your inpatient care if you utilize PMB services for outpatient sessions. PMBs are only available for certain ICD-10 diagnostic codes.
These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some patients feel that they need more services after medical aid benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, you will have the option available to you to pay cash for the sessions.
You should also be aware that most medical aid companies require that I provide them with your clinical diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the medical aid company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit, if you request it. You understand that, by using your medical aid, you authorize me to release such information to your medical aid company. I will try to keep that information limited to the minimum necessary.
Once we have all of the information about your medical aid coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by the medical aid contract].
I am often not immediately available by telephone, I am in session with clients and therefore unable to answer. The best platform to reach me is via messaging (whatsapp or SMS) or via my email address: [email protected]. You can contact my virtual receptionist on: 010 500 3228.
My working hours are from Monday to Friday between 10:00 and 17:00. I do not work weekends, unless I have specifically indicated that I am available to do so.
When I am unavailable, my telephone is answered by an answering service [machine, voice mail, or by my virtual secretary]. I monitor this frequently and will make every effort to return your call on the same day you make it, with the exception of: weekends, public holidays and planned/unplanned leave.
In emergencies, if you are unable to reach me and feel that you cannot wait for me to return your call, contact your general physician (GP) or the nearest emergency room and ask for the psychologist or psychiatrist on call. Alternatively you can contact:
~South African Depression and Anxiety Group (SADAG): 011 234 4837
~Akeso Psychiatric response unit (24 hours): 0861 435787
~Suicide Crisis Line: 0800 567567
If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
CONFIDENTIALITY FOR ADULT PATIENTS
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child [elderly person or disabled person] is being abused or has been abused, I must [may be required to] make a report to the appropriate state agency. If I believe that a client is threatening serious bodily harm to another (or myself), I am [may be] required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If a similar situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together.
Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you may have at our next meeting.
I will be happy to discuss these issues with you and provide clarification when possible. However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney. [If you request, I will provide you with relevant portions or summaries of the state laws regarding these issues.]
Your acceptance below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
I understand that this practice makes use of smeMetrics billing software and that my invoices, statements etc will be generated using this software. I understand that this practice makes use of an external practice administration firm Kitrin (Pty) Ltd. Services administered by Kitrin (Pty) Ltd include but are not limited to the invoicing, payment allocations and follow up on overdue accounts.
Whilst engaging in Psychotherapy sessions at: 340 on Main, Bryanston, I the client, accept full responsibility for my safety on the premises. I, the client, fully indemnify the therapist, Ashton Robertson, the landlord, the staff, and any other persons associated with this property. I, the client, indemnify the above mentioned persons, including, but not limited to: any injury, damage, loss, or death resulting from any cause whatsoever. In the case of minors, this indemnity is accepted, understood and signed by the legal guardian. Any person/s that accompany the client to the premises is also the full responsibility of the undersigned client. The cost associated of replacing, or repairing damage to any part of the property, however caused by any of the above mentioned, shall be paid for by the undersigned. Any medical conditions or allergies must be communicated by the client to the psychologist.
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.
As per outstanding invoices processed by Ashton Robertson.