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 process to me and I understand that I have the right to withdraw at any time. 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, 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 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>

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. I accept that appointments are taken as confirmed at the time of booking. Any reminders from Ilze Alberts 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.

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 myself using this software.

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

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.

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.

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.