Client Consent Form and Contract :: Ilze Alberts

I, the undersigned, grant Ilze Alberts permission to treat myself or legal guard in her capacity as a clinical psychologist. I accept that she does not do assessments or reports for legal purposes.

I, the undersigned, understand that Ilze Alberts is an Educational Psychologist and is registered with the HPCSA. Ilze Alberts will explain the therapeutic process to me and I understand that I have the right to withdraw at any time. I accept that consultations are recorded. I accept that information regarding my therapy may be communicated for referrals and supervision/consultation procedures. My information will remain confidential, however I understand that there are limits to confidentiality, including: should I be a risk to myself or others; when a child is in danger; if the court orders Ilze Alberts to reveal my information. Information can be used for research purposes provided my anonymity is assured.

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.

This Practice is a cash practice, Consultation fees must be paid for in full at the end of EVERY SESSION, EITHER IN CASH OR CARD (NO AMERICAN EXPRESS OR DINER’S). Arrangement for monthly payments to be made with Ilze.

The duration of a standard consultation is 50 – 60 minutes, with a fee of R3000.

The banking details are as follows:
Bank : Investec
Account : Ilze Alberts
Branch Name : Grayston
Branch Code : 58010500
Type of Account : Current/Cheque Account
Account Number : 10011219806
Reference : <Your Full Name>

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. With all rights reserved, Ilze Alberts 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 Ilze Alberts may suspend therapy until all outstanding accounts are settled in full.

24 hours’ notice to be given for cancellations, failing which, the full consultation fee will be charged. If the appointment falls on a Monday, the appointment must be cancelled on the Friday or the consultation will be charged for. I am reasonable and understand unforeseen circumstances. I request communication in time (where possible) if you cannot make your appointment. This ensures we build a mutually respectful professional relationship.

I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full. The debit order authorisation, as completed before, 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 Ingrid Nagaya 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 Ilze Alberts. With regard to minors, feedback sessions to parents are charged in full.

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.

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.

By signing this document, you acknowledge that you have read and agree to the above terms and conditions.

First Name *

Last Name *

Email *

Mobile Number *

Home Number

Work Number

ID Number *

Age

Date of Birth *

Would you like to receive my monthly newsletter with my informative blogs?

Residential Address *

Residential Address Postal Code *

Postal Address

Postal Address Postal Code

Occupation

Person/ Company Responsible for Account – Full Name *

Person/ Company Responsible for Account – Email Address *

Person/ Company Responsible for Account – Mobile Number *

Person/ Company Responsible for Account – Work Telephone Number *

Person/ Company Responsible for Account – ID Number *

Person/ Company Responsible for Account – Physical Address *

Person/ Company Responsible for Account – Physical 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 *

Bank Name *

Account Holder Name *

Account Number *

Account Type *

Branch Name *

Branch Code *

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 Ilze Alberts.

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 Ilze Alberts.