Kitrin

Your Growth is Our Business

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 Nature of Psychological Services

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 circumstances 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.  Psychological services may include assessment, diagnosis, treatment, and consultation. These services are designed to help you understand and address your mental health concerns.

Your treatment will begin with an initial assessment to understand your needs. Based on this assessment, we will create a treatment plan tailored to your specific concerns. The treatment may involve various therapeutic techniques and will require your active participation.  You have the right to ask questions about any aspect of your treatment.

Duration and Termination

The duration of treatment varies depending on individual needs and goals. You have the right to refuse, discontinue or terminate therapy at any time. If you choose to do so, it is recommended to discuss this decision with me to ensure a smooth transition.

Confidentiality

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(s). 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 there is suspicion of abuse or neglect of a child, elderly, or disabled person.
  4. If a court of law issues a legitimate request in writing for information stated on the written document.
  5. 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.
  6. 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.
  7. Confidentiality agreed on in relationship therapy include all parties involved.  This means that if you and your partner(s) accept the terms of this informed consent, no communication can be kept secret or exchanged in secret with me or withheld from your partner(s).  The confidentiality in relationship therapy is between all partners that is contracted herein.  All communication will be shared with all parties involved via a consented and agreed upon WhatsApp group or via email. 

Online Therapy Sessions

I am living as a digital nomad and therefore the practice operates exclusively online and no in person sessions are available. 

When we meet online ensure that you are comfortable and have a safe and private space to work.  Have some tissues on hand, if you think you might need it.  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 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.

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, for any reason, you are required to pay for that session.  This includes emergencies, hospitalisation or any other unforeseen event that prevents you from attending your session.  It is important to note that this cannot be claimed back through medical aid.

If you agree to this informed consent form you understand that if an appointment is not cancelled with 24-hour advance notice you will be charged in full.  You accept that appointments are taken as confirmed at the time of verbal booking. Any reminders serve as a courtesy and have no bearing on the confirmation of an appointment.

You also accept that any late coming will shorten the length of your session and you will be charged in full. Sessions cannot run overtime if the client is late.  Sessions will also be charged in full if you decide to end the session before your 50 minutes is up.

Rates and Medical Aid Claims

Sessions will be charged at R1,350.00 per session for individual therapy and R1,550.00 per session for relationship therapy.  This amount will be payable directly after each session. Sessions must be paid via EFT to reflect in the practitioner’s bank account by the time of your next session. Medical aid claims will not be sent to your medical aid by the practice. You will receive an invoice that can be used to claim back from your medical aid. 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. Software called smeMetrics is used for the administrative, invoicing and payment allocation processes.  An annual increase of between 5% and 10% (depending on the economy) will be applied in January of each new year.

If you agree to the terms of this informed consent form you agree to accept full responsibility for your account and to settle any outstanding payments. Moreover, you accept full responsibility to ensure that you have received the necessary invoices for sessions that you have attended.

With all rights reserved I, Chevon Cawood, have 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.

Should you not receive the related invoice, for sessions that are attended or missed, you will be responsible for ensuring that you follow-up and ensure that you do have a copy of the related invoice.  You understand that therapy may be suspended until all outstanding accounts are settled in full.

Record-keeping

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 with Veracrypt 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) at any time.  The only exception is when you are experiencing an emergency.  I am not reliably available enough to ensure your safety during an emergency.  In case of an emergency, please call Lifeline on (011) 715-2000, or go to the nearest hospital emergency room for assistance.

The psychological acts consented to above, do not pertain to forensic or medical-legal work. No assessments will be done for these purposes, and I will not appear in court on behalf of a client, unless I am served with a subpoena, in which case I will comply in terms of relevant legislation, Health Professionals Council of South Africa and the ethical requirements of the Professional Board for Psychology.

By electronically accepting the terms below, you acknowledge that you have read and understood the information provided in this form. You consent to receive psychological services from me, Chevon Cawood.

If you have any questions or concerns about this form or the services provided, please feel free to discuss them with me.