Client Consent Form and Contract :: Carmen Higgs
Welcome to my psychotherapy practice. In this document, you will find a client information form, and an informed consent form. Please could you kindly complete the forms prior to coming for your first session, otherwise alternatively, you can complete them on the day of your first appointment. Should you have any queries about the forms, I will happily discuss them with you at the next consultation. Please return completed forms to [email protected].
If you are attending couple’s therapy, please provide the client details of both partners in the first two tables below, as well as indicate which partner will be responsible for the account.
If the client is a child, please complete the child’s information in the first table below and the parent’s information in the second table and the person responsible for the account section. Please also complete the parental-child confidentiality agreement.
INFORMED CONSENT AND PROFESSIONAL THERAPEUTIC AGREEMENT
When clients enter into a formal therapy agreement, they have the following rights:
1: The right to confidentiality (and to be made aware of the limits thereof);
2: The right to enquire and ask questions about the therapy process, including assessment and treatment, therapist’s special interests and their limitations;
3: The right to a voluntary therapeutic process, which implies voluntary participation, refusal of a specific treatment intervention, negotiating alternatives and terminating the process if you see fit.
4: The right to be informed regarding fees for psychotherapy and method of payment, including medical aid and reimbursements.
The privacy of all communication in therapy is a crucial part of the therapeutic process. Please note that I can only release information about our sessions to others with your written permission/consent.
However, there are certain limits to this confidentiality rule where I do not need a client’s permission to break confidentiality, as set out below:
1: Under instruction by a Court of Law for legal proceedings, when information might be requested concerning the treatment of a client. Psychological files can be subpoenaed for legal purposes according to the relevant acts, and are subject to the Law before they are subject to therapeutic confidentiality clauses.
2: In circumstances where I am legally obliged to take action for the protection from harm of another, such as to report to relevant authorities when there are reasonable grounds for reported or suspected child abuse.
3:In the event that a client poses a clear and imminent danger either to him-/herself or someone else. Although these cases of rare, please take note that I am obliged to report such a danger or threat to appropriate parties, including the police, a particular threatened party and significant others of the clients, such as his or her spouse and family members. In this event, I will make every effort to discuss it with you first before taking action.
4: In the event that a client is found to be or becomes a vulnerable adult.
5: When the consultation with another health care provider such as a supervisor, psychiatrist or another psychologist is required in order to provide the most effective treatment to the client. In these circumstances, I will take extra care in the consultations to avoid revealing the identity of a client.
6 : When the client is a minor, in which case the parents / legal guardians ought to be made aware of the condition/diagnosis and progress of therapy. However, the content of the therapy sessions will remain confidential between client (child) and therapist.
7 : In all circumstances, reasonable efforts will be made to inform a client of a confidentiality breach and confidential information that is shared with the psychologist will be discussed with you.
Billing and Payment
For services rendered by Carmen Higgs, you (the client) agree to pay all charges for testing and psychotherapy sessions, in accordance with the standard terms set out below:
Cash Payments ::
The fees for cash payments are R890 per 55 minute session
The fee for cash payments are R1450 per 85 minute session (First appointments for couples therapy are usually 85 minutes, unless preferred otherwise).
The banking Details are as Follows
Account #: 10124629650
Branch code: 051001
Please reference with your name and surname
Medical Aid Claims ::
The therapy practice will claim directly from your medical aid, in accordance with your scheme and benefits available for psychological services.
• Carmen Higgs is registered with the Board of Healthcare Funders and consultation fees will be charged according to your medical aid rate, respectively.
• If you are not the principle/main member of your medical aid, you agree that the principle/main member is aware of the consultation and that they have given permission for the psychological sessions to be claimed from medical aid. Please note that the person whose signature appears on this document, unless a signed letter is received stating otherwise, will be held responsible for any outstanding amounts.
• You are aware that in the event of claiming through medical aid, the psychologist will need to submit an ICD-10 code to the medical aid which will give the medical aid an indication of the condition that you are being treated for. Clients have the full right to know what this code will be and discuss this further with the psychologist. If you refuse for this information to be submitted as a claim to the medical aid, you will be liable for the payment of the therapy sessions based on the cash rate of the practice.
• Payment for any psychological reports (following formal assessments only) as prepared by Carmen Higgs will be due and payable in full before it will be released to clients or any other party.
• Clients are personally responsible to know their insurance limits, exclusions, deductibles and payment structures, even though support staff do a preliminary check. Clients do not hold Carmen Higgs responsible for any errors or refusals of reimbursements for services rendered. Clients agree that they are responsible for the payment of all services for which their medical aids do not pay.
Cancellation Policy ::
• Clients are responsible to reimburse Carmen Higgs in full for any session that you either fail to attend, cancel or reschedule (without valid reason) without at least 24 hours prior notice (medical aids will not pay for late cancellations or missed appointments, late cancellation/missed session fee charged at R500).
• In the event that you miss two or more sessions without giving 24 hours’ notice, Carmen Higgs as your therapist, reserves the right to terminate our therapy relationship, in writing or telephonically.
• If you are 20 or more minutes late for your therapy sessions 2 or more times, Carmen Higgs as your therapist, reserves the right to terminate the therapy relationship, in writing or telephonically.
Overdue Payments Policy ::
• You understand that your email address and contact number provided will be used for all correspondence related to appointments and invoices. You are responsible to follow-up on any invoices not received 5 days following a therapy appointment.
• You agree that at no time will an outstanding fee-for-service balance of more than R2000.00 be allowed and that therapy may be temporarily suspended or terminated until sufficient payment has been received to place your outstanding balance below this amount.
• You agree that if your therapy account has not been paid for a period of 30 days or more, the full payment will be processed against the authorised bank account. You will be notified of any unpaid invoices or medical aid claims prior to this debit order authorisation.
• A collection agency or attorneys’ firm may be employed after your account balance becomes 90 days overdue, with the express purpose of collecting any past due-debts that you might owe Carmen Higgs. In this regard, you consent to payment of all legal costs on a scale as between attorney and client, including (but not limited to) collection commission and tracing fees. For this purpose, you agree to the release of your personal information to such collection agency or attorneys’ firm to facilitate collection of the outstanding account.
• You hereby choose the physical address as set-out on the front of this agreement as my domicilium citandi et executandi for the delivery of all and any notices or pleadings related to any attempts made to facilitate collection of your outstanding account.
I understand that Carmen Higgs may suspend therapy until all outstanding accounts are settled in full.
STANDARD THERAPEUTIC INFORMATION
In the case of any psychological or medical emergency, please could you go to the emergency or casualty rooms of the nearest hospital.
Alternatively, please contact:
• 10111 for Police services
• 10177 for Medical Ambulance Services
Contact Details of the Practice
Reception: (Cellphone) 0840114444, (Email) [email protected]
You are welcome to make appointments with reception from Monday to Friday 08:00-17:00. Alternatively, you can also send an SMS, WhatsApp or email to these contact details at any hour. However, reception will only respond to your message within working hours (as stipulated above). Please take note that appointment requests will generally be attended to after 17:00.
Personal Contact and Social Media Policy
Please take note that your questions and concerns will be addressed during therapy sessions only. I am not able to provide therapy over sms, email or cellphone, especially not prior to a first session taking place.
Social media policy:
In line with ethical guidelines and policies, I do not accept any form of interaction with current or past clients outside of the therapy space. This includes facebook, linkedIn and Instagram to name a few. In the event that I might see clients in a non-therapeutic space, I might opt not to greet or acknowledge
you in public. These are some of the ways in which I maintain strict confidentiality, as well as give great value to the power of a therapeutic-only relationship.
Psychotherapy Frame and Duration
The initial assessment stage of therapy, which is aimed at assessing your concerns and difficulties, can range over a few sessions. If after this, you agree to proceed with psychotherapy, sessions are generally scheduled on a weekly basis at a time that is suitable for you. The session duration is strictly 55-minutes. The treatment frame is difficult to establish as it depends on a range of factors, such as time allowances, finances and personal circumstances of each client. However, an approximate number of sessions required will be discussed with you and continually re-assessed throughout the therapy process.
Psychotherapy Expectations, Risks and Discomfort
It is important to remember that psychotherapy involves benefit, as well as risk. During the process of psychotherapy, some psychological pain and discomfort may arise as sensitive and personal difficulties are explored. This might occur in the form of uncomfortable emotions, such as sadness, resentment, helplessness, anger or guilt. Client dedication and commitment remains a significant aspect of the therapy process and should be prioritised.
At times, you might not obtain the desired results or goals from therapy in the time period expected. This can lead to frustration and/or disappointment. Please feel free to discuss this with me at any given time.
In the event that clients feel that they would benefit more by seeing another healthcare professional, I will gladly assist in the referral process. I strongly believe in therapist-client fit and will also assist with a referral in the event that I or the client experiences the therapeutic fit to not be beneficial or effective for a meaningful therapy process.
Please be aware that the psychologist (Carmen Higgs) will not be liable for any claims for any losses or damages suffered as a result of psychotherapy treatment (to the extent permitted by law).
Please take note that the nearest paid parking is available at Stelkor. The practice is on the first floor of the Oppiedorp Restaurant. I am not able to open the gate before the exact time of the appointment as I am likely to be in another session.
CONSENT FOR ONLINE PSYCHOTHERAPY
The purpose of this informed consent for technology-assisted psychotherapy is to inform you, the client, about the process of online therapy and the potential risks and benefits of these services. This consent form is an addendum to the face to-face informed consent that you will be required to sign. Please familiarise yourself with the details surrounding online therapy so that you are informed about the process that you are consenting to.
Benefits and Limitations
It is sincerely my hope that you will benefit from online psychotherapy as all or part of your psychotherapy process, but due to the fact that there will not be face-to-face interaction, the impact of the relational experience and therapeutic relationship might or might not influence the treatment plan and process. It is also not the most appropriate medium of therapy if you are severely depressed, have
a serious substance abuse dependence, experience psychotic symptoms, or have serious suicidal or homicidal thoughts.
Privacy and Confidentiality
Online therapy utilises the internet for the transmission of personal information. Therefore, there are increased risks to confidentiality that cannot be guaranteed. The information disclosed during the course of my therapy session with you is strictly confidential. However, there are legal exceptions both mandatory, and permissible to this confidentiality rule, including child, elder, and dependent adult abuse; threats of harm to self or others, or if court ordered. I will take all precautions to ensure that your online therapy process is and remains confidential, such as using services that require encryption to communicate. Due to the nature of online psychotherapy, please can you be informed that transmission could be disturbed or distorted by technical failures or interrupted or accessed by unauthorised persons. This could result in confidentiality breaches in transit. The psychotherapy session will not be allowed to be recorded, unless pre-arranged for therapeutic purposes and should not be shared on social media. Please take note that you are responsible to secure your own phone or computer hardware, internet access point, email, passwords and interaction platforms. Any computer files referencing the therapeutic communication will be maintained using secure and encrypted measures. Please could you consider password protecting the device that you use and installing antivirus software to prevent access by third parties.
Technological Requirements and Competences
In order to engage with online psychotherapy, you will be required to have a device that can connect to the internet for 52 minutes, as well as be able to install the Zoom application (HIPAA compliant software) that is the preferred method of communication for online psychotherapy for your Clinical Psychologist, Carmen Higgs. Please be mindful of data usage during online therapy sessions, especially when video sessions are utilised.
ZOOM: The way in which the online sessions will work
1) You are welcome to download Zoom prior to your session (More convenient)
2) I will send you an email 5 minutes before every session with a link and a Meeting ID and password.
3) If you have downloaded Zoom already, in the email, you can either 1) Press the url link and “Join Zoom Meeting” or if you have downloaded Zoom already as an app, use the “Meeting ID and Password” in the email to enter the zoom meeting.
Procedures for Technical Difficulties and Disruptions
It is understood that when relying on internet to communicate for online therapy sessions that disruptions may occur from time to time. Should our communication be disrupted, I will immediately attempt to reconnect and resume the session. However, if I am repeatedly unable to reconnect after several attempts or 10 minutes, you agree to phone me on 0840114444 for the remainder of the therapy session.
It can be challenging to deal with emergency crisis situations when using online therapy as we are often in separate locations. In the event of a crisis or emergency, please go to your nearest casualty/emergency hospital or police station. I am also happy to assist you with a referral to see another mental healthcare provider in your area in these extreme circumstances.
I understand that that the email address and mobile number provided 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.
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.
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.
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.
As per outstanding invoices processed by Carmen Higgs.
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.
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.