I, the undersigned, grant 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 the therapist to interview, assess and treat me according to the guidelines and terms mentioned below
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.
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.
I understand that Rooted In Love Counselling’s consulting fees are in accordance with the Board of Healthcare Funders of South Africa. I accept that sessions are subject to annual increase.
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 will be ended immediately and billed for in full, should there be the presence of intoxication or influence of substances.
Appointments need to be cancelled with 24 hours notice to avoid being billed in full. The same applies to missed appointments. This fee will be waived if a doctor’s note is produced.
Should two (2) consecutive appointments be missed, the standing appointment will be cancelled going forward and will need to be rebooked.
Rescheduled appointments are subject to availability and are scheduled for the following day. Alternatively, this will be considered a cancelled/missed appointment and billed accordingly.
Patients are responsible for submitting receipts/statements for reimbursement. This practice is not responsible for failure of reimbursement from your medical aid scheme.
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.
If my invoices are paid at private rates, I understand that it is my responsibility to make payment on the date of the therapy session.
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.
I understand that if an appointment is not cancelled within 24 hour advance notice, I will be billed in full for the sesson. 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 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 Rooted In Love Counselling With regard to minors, feedback sessions to parents are charged in full.
I understand that 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, 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.