Welcome to Rooted in Love Counselling. My name is Simone Poppleton and I am a Registered Counsellor (HPCSA: PRC 0716049) and relationship specialist. I appreciate you giving me the opportunity to guide you and your relationships on the art of connection and empathic communication.
This form will help provide necessary information for the therapy process and layout your rights and responsibilities as a client. It is important that you know how we will work together. Please read through the Client Service Agreement and write down any questions you may have so that we can discuss them in our next session.
When you sign this document it will represent an agreement between us.
APPROACH TO THERAPY
In therapy I focus on crating a safe and inviting environment where my clients can resolve past problems, manage more successfully with current life challenges and strive toward a more meaningful and wholehearted future. I work from a relational approach which means I believe the quality of our lives is determined by the quality of our relationships. I take a holistic and systemic view of individuals and couples and view my clients as the integration of the mind, body and soul.
We work collaboratively to determine your therapeutic goals.
I do recommend that clients are willing to contract for at least 6 sessions. After 6 sessions we will have a review of the work done so far in order for you as the client to evaluate your progress. We should and will discuss your progress regularly.
The outcome of counselling is mostly dependent on the quality of the relationship between the therapist and the client. This involves us creating a strong alliance as counsellor and client built on unconditional acceptance, zero judgement and empathy.
A positive therapeutic engagement necessitates regular attendance, self disclosure, transparency and commitment to the therapy process.
If you are unhappy with what is happening in therapy, I hope you will talk to me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You are free to end therapy at any time.
Sessions will be ended immediately and billed for in full, should there be the presence of intoxication or influence of substances. I am not under any obligation to provide services to people who are aggressive or harassing of me.
RISKS AND BENEFITS
Counselling has risks and benefits. Risks may include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, loneliness and helplessness, because our sessions may bring up difficult experiences. However counselling has been shown to have benefits for individuals too. It can lead to mood regulation, emotional regulation, improved communication, conflict management, a reduction in feelings of distress, greater satisfaction in interpersonal relationships.
I often tell clients that it may seem as if things are getting worse before they get better. Within the first few sessions you may see an increase in negative emotions or behaviours, if you notice these changes, please communicate this with me.
CONFIDENTIALITY AND INFORMED CONSENT
I, the undersigned, understand and acknowledge the following.
All information will be treated as confidential. There are times where a legal or ethical obligation rests on the therapist to disclose information. It is required by law to report to the appropriate authorities any suspected, past or present, child abuse, elder abuse or abuse of people with disabilities. When a threat of bodily harm to self or others is present, the therapist will break the confidentiality of communications. This includes receiving a court order for disclosure.
Prior to breaching confidentiality I will inform you and discuss the possible outcomes of doing so in order to work collaboratively and resolve the matter in a way that would be in the best interests off the client.
With consent, relevant information may be discussed with the referring psychiatrist or other mental health professionals registered with the Health Professions Council or South African Social Work Council.
At times I may consult with other counsellors or supervisors. During consultation with these professionals, identifying information will be kept to an absolute minimum and only what is absolutely necessary. The purpose of consultation is to ensure that I am maintaining a high quality of care and providing the most appropriate treatment at all times.
You are free to end therapy at any time. You have the right to considerate, safe and respectful care and not to be discriminated against on the basis on race, ethnicity, colour, gender, sexual orientation, age or religion.
The time scheduled for your appointment is assigned to you and you alone. You are responsible for attending the session on time. 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. If you are more than 15 minutes late, we would need to reschedule as there would be insufficient time to do meaningful work.
I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Rooted in Love Counselling serve as a courtesy and have no bearing on the confirmation of an appointment.
I understand that if an appointment is not cancelled within 24 hour advance notice, I will be billed in full for the session. Please note that such penalty fees cannot be submitted to medical aids and you will be directly responsible for this.
Following 2 consecutive late cancellations your appointment time will be forfeited and we will need to discuss an alternative option as well as the appropriateness of therapy at this time.
Rescheduled appointments are subject to availability. Alternatively, this will be considered a cancelled/missed appointment and billed accordingly.
Consultation fees are payable prior to each session via EFT, unless alternative arrangements have been agreed on. This includes any and all legal costs resulting from legal action/ debt collection for overdue accounts.
Sessions are subject to annual increase.
Please note that you are fully responsible for your account for settling any outstanding payments. Moreover, please accept full responsibility to ensure that you have received the necessary invoices for sessions that you have attended. I am registered with the Board of Healthcare Funders (BHF), therefore clients can submit their paid invoices to their medical aid claims department for possible refund.
If you wish to confirm benefits with your medical aid, it is useful to contact your funder directly. I do not liaise with medical aids to confirm benefits.
The banking details are as follows:
Bank : First National Bank
Account : Rooted in Love
Branch Name : Melville
Branch Code : 250655
Type of Account : Current/Cheque Account
Account Number : 62750071468
Reference : Your Full Name
I understand that Rooted in Love Counselling may suspend therapy until all outstanding accounts are settled in full.
If you are having trouble settling your account, please speak to me about this so that we may come to an acceptable arrangement together.
Telehealth is enabling us to continue to connect therapeutically online. I utilize Zoom as the preferred method for teletherapy consultations in my practice.
Please familiarise yourself with the following information:
The HPCSA regulations that protect the confidentiality of information also apply to telehealth. All information disclosed in our online session is confidential.
Please note that there are risks in participating in teletherapy, including the possibility, despite best efforts, that the service be disrupted or distorted by unforeseen technical problems.
As your counsellor I can only account for 50% of the online therapy space. I ensure that my space is private and confidential with sufficient lighting for our sessions. Therapy is for you, and you alone. It is your responsibility to find a safe, private and confidential space for our sessions. If your environment is not conducive for us to have a safe, private and confidential session I reserve the right to suggest an alternative time to meet, and this session will be billed accordingly.
Telehealth does not provide emergency services. If you are experiencing an emergency situation please proceed to your nearest emergency room for help or contact
- Akeso Psychiatric Response Unit 24 Hour Helpline (0861435787)
- Cipla 24hr Mental Health Helpline 0800 456 789 or Whatsapp 076 88 22 775
I am available for clients to contact me via email, or Whatsapp messages between 9am and 7pm SA times on weekdays and between 9am and 12pm on Saturday. Please ensure you contact me on professional platforms and not via social media. If I do not reply I may be in a session or busy with another obligation. If I do not answer kindly send me a Whatsapp message outlining your needs so that I can respond as soon as possible.
This practice makes use of billing software called smeMetrics, all invoices will be sent to you using this software.
Rooted in Love Counselling practice makes use of Kitrin (Pty) Ltd to manage all administration aspects of the practice including but not limited to invoice submission through smeMetrics, unpaids management and medical aid follow ups.
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.
I, the client, grant the counsellor, Simone Poppleton T/A Rooted in Love Counselling permission to treat myself or legal guard in her capacity as a registered counsellor. I hereby give permission to my counsellor to interview, assess and treat me according to the guidelines and terms mentioned above.