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 psychologist.

I, the undersigned, understand that Ilze Alberts is an Educational Psychologist and is registered with the HPCSA. Ilze Alberts will explain the therapeutic or mentoring process to me and I understand that I have the right to withdraw at any time. 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. 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, via EFT. Arrangement for monthly payments or packages to be made with Ilze. The duration of a standard consultation is 50 – 60 minutes, with a fee of R2500.00 including VAT.

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 :

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 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 understand that this practice makes use of billing software called smeMetrics, all invoices will be sent to me using this software.

I understand that this practice makes use of Kitrin (Pty) Ltd to manage all administration aspects of the practice including but not limited to invoice submission through smeMetrics.

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

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? *

Yes
No

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 *

I have read, understood, and agree to the terms related to the payment terms of the practice *

Yes
No

I have read and understood that this practice makes use of an external practice administration company Kitrin (PTY) Ltd and grant permission for them to contact me in regards to any queries about my account. *

Yes
No

I understand that this practice makes use of smeMetrics billing software *

Yes
No

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

Yes
No

CONTRACT TERMS

PRICING
As per outstanding invoices processed by Ilze Alberts.

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.