Client Intake Form :: Chevon Cawood

Client Details

Please complete your details below. Your information will then be loaded onto our client management and billing systems for processing.

Client Intake Form Acceptance

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 invoice.

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. 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, Chevon Cawood 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 Chevon Cawood may suspend therapy until all outstanding accounts are settled in full.

I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full.  I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Chevon Cawood serve as a courtesy and have no bearing on the confirmation of an appointment.

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.

First Name

Last Name

Email Address

Mobile Number

Preferred Name

Sex

Male
Female
Other

Marital Status

Single
Married
Living Together
Separated
Divorced
Widowed / Widower
Remarried

Home Language

Date of Birth

ID Number

Age

Residential Address

Residential Address Postal Code

Postal Address

Postal Address Postal Code

Occupation

Work Company Name

Work Telephone Number

Work Company Address

Next of Kin – Full Name

Next of Kin – Email Address

Next of Kin – Mobile Number

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

Referral Source – Full Name

Referral Source – Email Address

Referral Source – Contact Number

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?

Yes
No

Number of Persons in Home – Adults (Family)

Number of Persons in Home – Adults (Other)

Number of Persons in Home – Minors

Highest Educational Qualification

Unknown
Less than Grade 8
Grade 8-9
Grade 10-11
Grade 10-11 + Diploma
Grade 12
Graduate
Postgraduate
Other

Current Employment Status

Unemployed
Employed
Self-employed
Other

Current Medical Conditions or Allergies

Medication and Doses

Relevant Medical History

History of Substance Abuse (Past)

N/A
Over the counter
Alcohol
Cigarettes
Marijuana
Cocaine
Heroin
Other

History of Substance Abuse (Current)

N/A
Over the counter
Alcohol
Cigarettes
Marijuana
Cocaine
Heroin
Other

Previous History of Legal Problems

N/A
Criminal Record
Current Legal Problem
Other

Family Psychiatric History (or Suspected) – Maternal Side (include relation to patient and diagnosis)

Family Psychiatric History (or Suspected) – Paternal Side (include relation to patient and diagnosis)

I have completed, read, understood, and agree to the Informed Consent for Psychotherapy practices contained herein.

Yes
No

I have read, understood, and agree to the Client Intake Form info contained herein. *

Yes
No

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