I, the undersigned, hereby give permission to the therapist/psychologist to interview, assess and treat myself according to the guidelines\terms mentioned below:

Therapeutic Services, Benefits, Risks & Alternatives

I understand that therapy is not easily described in general statements. It varies depending on the personalities of the therapist/psychologist and patient, and the particular problems I may be experiencing. During the course of our work together, the therapist/psychologist may use various psychological approaches depending on the problem(s) being addressed and their clinical judgement of what will benefit me. In general, the therapist/psychologist uses an approach described as the “psychodynamic therapy.” Psychodynamic therapy focuses on talking therapy. This means that it is based on the concept that talking about problems can help me learn and develop the skills I need to address them. It is an approach that embraces the multifaceted aspects of my life. I understand that it involves the interpretation of my mental and emotional processes rather than focusing on my behaviour. In my consultations we will attempt to find patterns in my emotions, thoughts, and beliefs in order to gain insight into what is happening in the here and now.

Most people that obtain therapy benefit from the overall process. The benefits may include relief of specific symptoms (e.g., anxiety, depression, and fears), improved interpersonal relationships, greater self-confidence, easier decision-making, and improvement in the specific concerns that led me (or me and your partner/family member) to seek therapy. Success may vary depending on the particular problems being addressed. Therapy involves active participation, self-exploration, gaining new understandings of one-self and others, finding ways of dealing with problems, and learning new skills. Typically the length of therapy is determined by our collaborative discussion and agreement as we work together. However, we can agree on a predetermined number of sessions or length of time at the outset. The length of therapy needed usually depends upon the extent and severity of my specific problems, practical considerations that may impact my ability to commit time and financial resources, any preferences that I may have, and the therapist/psychologist’s recommendation.

If I could benefit from any interventions that the therapist/psychologist does not provide, they are ethically obligated to assist me in obtaining those services. If at any point during therapy the therapist/psychologist decides that they are not being effective in helping me make progress toward my therapeutic goals, they are obligated to discuss it with me and, if necessary, end the therapy. I may also end the therapy at any time, although the therapist/psychologist would prefer that we discuss my intentions in a session or two before we end. In either case, the therapist/psychologist would give me appropriate referrals and, if I request and authorize it in writing, they can talk with the therapist of my choice to ease the transition to that professional.

Psychometric Services, Benefits, Risks & Alternatives

Psychometric testing varies in purpose, and below are some of the common features for me to consider:

Clinical Interview – A structured clinical interview with me which finds out my background information (e.g., family history, physical health, prior abuse history), mental health concerns, education/work history, employment, social functioning, and a mental status exam. With my express consent, contact may be obtained from my family members or relevant stakeholders to provide additional information to facilitate the testing process.

Mental Health Assessment Inventories – These inventories typically include surveys or performance exercises that would assess various mental health symptoms.

Cognitive/Neuropsychological Assessment Tools – These exercises may include tests of cognitive ability, academic achievement, visual-motor coordination, attention span, neurological functioning, memory and processing speed.

Validity Assessment – The therapist/psychologist assesses my truthfulness based on my presentation during the clinical interview; consistency of my report with prior records and history; my effort on the testing exercises; and my response pattern on the administered psychological tests. Therefore, it is extremely important that I am as truthful as possible with the therapist/psychologist on the test surveys, and provide my best effort on the varied psychological tests. The therapist/psychologist will determine that the test results appear to either be valid, interpreted with varied degrees of caution, or be declared invalid altogether if it is discovered that I am not truthful or I provided a poor effort.

Feedback – After the test results are obtained, the test data is interpreted into a coherent psychological report. The psychological report reviews the data, provides detailed analysis of the mental and cognitive test results, summarizes the data, and lists diagnostic impressions. Additionally, recommendations specific to my needs will be listed at the conclusion of the psychological report to provide me with further direction.

Client Privacy & Confidentiality

I have the right to confidential treatment and confidentiality will be maintained and information regarding my communication(s) with the therapist/psychologist, treatment and management will be released only to qualified professionals that I have explicitly advised the therapist/psychologist to release this information to. However, confidentiality can and will be broken in certain situations where maintaining confidentiality would result in clear and imminent danger to myself or others or as otherwise provided by law. Furthermore, I understand that confidentiality cannot be ensured with regards to Forensic and Medico-Legal assessments\consultations\evaluations.

My therapist/psychologist is required, according to the Ethical Code of Conduct governing the Profession (the HPCSA), to keep brief records (that are maintained in a secure place) concerning our interactions\communications. These records also include interventions used during the sessions and topics discussed. You may request a copy of your file in writing, provided that this does not cause you harm, giving your therapist/psychologist a reasonable amount of time to make the copy and at a reasonable cost (not claimable from medical aids), which will be discussed with you.

My therapist/psychologist has my permission to release my ICD-10 code (International Statistical Classification of Disease and Health problems code) to medical aids\third parties in order to receive payment and further treatment for myself.

The therapist/psychologist is required by law to report to the appropriate authorities any suspected child abuse, elder abuse or abuse of people with disabilities. When a threat of bodily harm to others or myself is present, the therapist/psychologist may break the confidentiality of communications. I understand that the therapist/psychologist will make reasonable efforts to resolve these situations before breaking confidentiality.

Telepsychology & Virtual Consultations

I understand that should I request to consult with the therapist/psychologist via Facetime, WhatsApp video calling, Skype, or Zoom platforms it is not a usual means of consultation. Thus I accept that full confidentiality with the use of the above platforms cannot be fully guaranteed and I absolve therapist/psychologist from any liability for damages suffered as a result of a breach in confidentiality. I also accept that should my medical insurer/scheme refuse to pay the consultation and/or only agree to pay a partial amount, I will be personally liable for the outstanding fees.

Considerations & Obligations

I understand that if I choose to communicate with the therapist/psychologist electronically, that these mediums are not completely confidential, due to hackers and system administrators. The therapist/psychologist will, however, do their best to ensure the confidentiality of our communication and through password protection of the various mediums of communication. I will allow 72 hours for the therapist/psychologist to respond to my email/message. If I still have not heard from the therapist/psychologist, I will resend my email/message as it is possible that it was not received. If the matter is urgent then I will contact the therapist/psychologist telephonically.

The therapist/psychologist charges a fee for consultation and/or therapy. The per session fee is due regardless if I arrive late or decide to leave early. If I do come late I cannot extend the session to make up for the lost time.

The therapist/psychologist charges a fee for psychological testing, which includes time for test administration, scoring, interpretation, contacting other professionals that have worked with me (with my express permission), report writing, and feedback.

Telephonic conversations outside of our sessions are free for up to 10mins; however the moment they exceed that duration they prorated according to the per session fee. Other related services such as attendance at meetings, site visits, performance observations, home visits, authorized consultations, preparation of records or treatment summaries, travel time, or other services I may request are billed at an hourly rate.

There are no fees for sessions that I cancel or change 24hrs or more prior to a scheduled appointment. Sessions which are missed without at least 24hrs prior notice of cancellation are charged the full fee. We can attempt to re-schedule a missed or cancelled session for the same week, but the therapist/psychologist cannot guarantee that they will have another time available.

The therapist/psychologist has a practice administration team – Kitrin (PTY) Ltd – that will send my service statement on the 20^th day of every month or the first working day thereafter. Payment in full is due within two weeks after I receive the fee statement, unless we agree to a special arrangement that works better for me. If during our work together it becomes impossible for me to keep on track with my fee payments and I would like to continue receiving services, we can negotiate a reasonable payment schedule. However, non-payment of fees could result in having to end our work together, at least temporarily, until my outstanding balance is paid.

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.

AGREEMENT
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