Informed Consent for Psychotherapy
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by accepting the terms at the end of this document.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behaviour or circumstance will change. I can promise to support you and do my very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself.
The session content and all relevant materials to your treatment will be held confidential unless you as the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of your client held privilege of confidentiality exist and are itemised below:
1. If you threaten or attempt to commit suicide or otherwise conduct yourself in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If you threaten grave bodily harm or death to another person.
3. If a court of law issues a legitimate request in writing for information stated on the written document.
4. Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
5. If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardise your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
Appointments and Cancellation Policy
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. If you miss a session without cancelling, or cancel with less than 24 hours’ notice, you are required to pay for that session. It is important to note that this cannot be claimed back through medical aid.
Rates and Medical Aid Claims
Sessions will be charged at R950.00 per session. This cash rate is less than the medical aid rates and if the account is sent to your medical aid, medical aid rates will apply. If the medical aid does not pay the account, for any reason, you will be responsible for the outstanding amount on your account. Please note that both/all individuals in relationship therapy will be held responsible for the account. Unpaid accounts, outstanding for 60 days or more, will be handed over to a debt collection service, called KITRIN IsoForge. All administration and invoicing are outsourced to KITRIN and they make use of a software called smeMetrics for the invoicing, payment allocation and medical aid submission processes. An annual increase of between 5% and 8% (depending on the economy) will be applied in January of each new year.
I keep brief records, noting that you have been here, what interventions occurred during your session, and the topics we discussed. All personal information and session records are stored electronically. All information is encrypted and protected with a password. Disclosure of a diagnostic code is necessary for purposes of medical aid claim submission. If you do not want me to disclose the diagnostic code, please inform me thereof and the code U98.1 “client refuses disclosure” will be reflected.
Contact & Emergencies
You may contact me via phone, text (sms or whatsapp) or email (please note that email is not completely confidential). If you are experiencing an emergency when I am out of town, or outside of my regular office hours (after 6 pm weekdays or over the weekend), please call Lifeline on (011) 715-2000, or go to the nearest hospital emergency room for assistance.
Online Therapy Sessions
Ensure that you are comfortable and have a safe and private space to work. Choose a conﬁdential space where you will not be overheard. Communicating through the internet or other electronic or telephonic means may be disrupted by technical difﬁculties, load shedding, break in service or other unforeseen difﬁculties. If technical difficulties are experienced, we will undertake to contact each other via text (SMS) message or phone call so that an alternative session can be made. Please kindly ensure that you have a stable internet connection. Working online has the inherent risk of potential breaches of confidentiality. When working online it is important to maintain security through reasonable measures to ensure confidentiality and safe working procedures. Please ensure the device you are using is safe and that no one else has access to it. Recording of or screen shots of the session is not permitted. It would not be appropriate to post/share onto social networks/forums any recorded or written correspondence between us from our work together. Should online therapy not be appropriate for your need, a possible referral will be provided, or an appointment will be given for a face to face session, or the process will be postponed until a face to face session can be arranged.
Forensic or Medical-Legal Work
The psychological acts consented to above, do not pertain to forensic or medical-legal work. No assessments will be done for these purposes and the psychologist will not appear in court on behalf of a client, unless the psychologist is served with a subpoena, in which case the psychologist will comply in terms of relevant legislation, Health Professionals Council of South Africa and the ethical requirements of the Professional Board for Psychology.
Informed Consent Form Acceptance
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 invoice.
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. 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, Chevon Cawood 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 Chevon Cawood 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. I accept that appointments are taken as confirmed at the time of verbal booking. Any reminders from Chevon Cawood serve as a courtesy and have no bearing on the confirmation of an appointment.
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.