Client Consent Form and Contract :: Sample Practitioner

I, the undersigned, grant Sample Practitioner permission to treat myself or legal guard in her capacity as a clinical psychologist. I accept that she does not do assessments or reports for legal purposes.

I, the undersigned, understand that Sample Practitioner is a Clinical Psychologist and is registered with the HPCSA. Sample Practitioner will explain the therapeutic process to me and I understand that I have the right to withdraw at any time. I accept that consultations are recorded. 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 Sample Practitioner to reveal my information. Information can be used for research purposes provided my anonymity is assured.

I understand that Sample Practitioner’s consulting fees are in accordance with the Board of Healthcare Funders of South Africa. I accept that sessions are charged at medical aid rates and are subject to annual increase.

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. Sample Practitioner will make available credit and debit card facilities to make this payment process possible.

If my invoices are being submitted to medical aid, I understand that it is my responsibility to liaise with my medical aid regarding payments due and keeping up-to-date with my available funds. If my account has not been paid for a period of 30 days or more, the full payment will be processed against the authorised bank account. If you’re a medical aid client, a payment on your account will only be processed if the medical aid has not paid the submitted invoice, and it is clearly indicated on the medical aid remittance. You will be notified of this rejection, and of the date that the payment will be processed on your account. The estimated time to get a payment from the medical aid is 4-6 weeks from the date that the invoice is submitted. With all rights reserved, Sample Practitioner 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 Sample Practitioner may suspend therapy until all outstanding accounts are settled in full.

I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full. The debit order authorisation, as completed before, will be used to process payment against your authorised bank account. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Sample Practitioner 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 Sample Practitioner. With regard to minors, feedback sessions to parents are charged in full.

I understand that that the email address and mobile number provided 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.

The contract terms in terms of the debit order can be found lower on this page, for your reference.

First Name

Last Name

Email Address

Mobile Number

Preferred Name

Sex

Male
Female
Other

Marital Status

Single
Married
Living Together
Separated
Divorced
Widowed / Widower
Remarried

Home Language

Date of Birth

ID Number

Age

Residential Address

Residential Address Postal Code

Postal Address

Postal Address Postal Code

Occupation

Work Company Name

Work Telephone Number

Work Company Address

Next of Kin – Full Name

Next of Kin – Email Address

Next of Kin – Mobile Number

Person Responsible for Account – Full Name

Person Responsible for Account – Email Address

Person Responsible for Account – Mobile Number

Person Responsible for Account – ID Number

Person Responsible for Account – Home Address

Person Responsible for Account – Home Postal Code

Person Responsible for Account – Company Name

Person Responsible for Account – Work Telephone Number

Person Responsible for Account – Work Address

Person Responsible for Account – Work 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

Permission to submit diagnosis code to medical aid?

Yes
No

Number of Persons in Home – Adults (Family)

Number of Persons in Home – Adults (Other)

Number of Persons in Home – Minors

Highest Educational Qualification

Unknown
Less than Grade 8
Grade 8-9
Grade 10-11
Grade 10-11 + Diploma
Grade 12
Graduate
Postgraduate
Other

Current Employment Status

Unemployed
Employed
Self-employed
Other

Current Medical Conditions or Allergies

Medication and Doses

Relevant Medical History

History of Substance Abuse (Past)

N/A
Over the counter
Alcohol
Cigarettes
Marijuana
Cocaine
Heroin
Other

History of Substance Abuse (Current)

N/A
Over the counter
Alcohol
Cigarettes
Marijuana
Cocaine
Heroin
Other

Previous History of Legal Problems

N/A
Criminal Record
Current Legal Problem
Other

Family Psychiatric History (or Suspected) – Maternal Side (include relation to patient and diagnosis)

Family Psychiatric History (or Suspected) – Paternal Side (include relation to patient and diagnosis)

I have completed, read, understood, and agree to the Informed Consent for Psychotherapy practices contained herein.

Yes
No

I have read, understood, and agree to the Client Intake Form info contained herein. *

Yes
No

Website

CONTRACT TERMS
The following are the terms of the debit order for your reference:
This signed Authority and Mandate refers to our contract as dated as on signature hereof (“the Agreement”). I/We hereby authorise you to issue and deliver payment instructions to the bank for collection against my/our abovementioned account at my/our above mentioned bank (or any other bank or branch to which I/We may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of no less than 30 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above.

The individual payment instructions so authorised to be issued must be issued and delivered as follows:
Daily; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due;

I/We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.


MANDATE
I/We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.


PRICING
As per outstanding invoices processed by Sample Practitioner.

CANCELLATION
I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.


ASSIGNMENT
I/We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.


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 Sample Practitioner.