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.
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.