I, the undersigned, hereby give my informed consent for my child as named below, to be psychologically assessed/ attend individual psychotherapy according to the guideline and terms listed below
- I understand that all information will be treated as confidential. I understand that there are times where a legal or ethical obligation rests on the therapist to disclose information. The therapist is required by law to report to the appropriate authorities and 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 my break the confidentiality of communications. This includes the therapist receiving a court order of disclosure.
- I also understand that, with my consent, relevant information may be disclosed with the referring psychologist/ psychiatrist or other mental health care professionals registered with the Health Professions Council of South Africa, or the South African Social Work Council. I understand that this is to enable the professional team to work together to get my child the best treatment possible.
- I understand that no information will be disclosed to my child’s school/teacher/others without my consent.
- I understand that my child’s therapist does not do forensic work, unless served with a subpoena to appear in court. I further understand that any information or report obtained from the therapist may not be used for legal purposes.
- As my child’s parent/guardian, I understand that I may be required to continue certain therapeutic techniques with my child at home, as recommended by my child’s therapist. I am committed to working together with my child’s therapist in an effort to ensure the best treatment for my child.
- I understand that as a parent/guardian , I have the right to request periodic feedback on my child’s general progress in therapy and understand that in order to respect the confidentiality of my child, I will refrain from requesting detailed information about the individual therapy sessions.
I further acknowledge and agree to the following terms:
- I understand that I am responsible and liable for my child’s consultation fee, which is payable at the end of each session via cash or EFT, unless alternative arrangements have been agreed on. This includes any legal costs resulting from legal action/debt collection against me for not settling my account.
- I understand that overdue accounts may be claimed for directly from my medical aid.
- I acknowledge that interest accrues at 1.5% on late or overdue payments.
- If the therapist spends more than 10 minutes a week responding to my phone calls with regards to my child’s care, treatment or management, I will be billed accordingly for this time.
- I understand that if my child is more than 20 minutes late for an appointment, they will forfeit the appointment and I will be liable for the costs.
- I understand that, should I cancel an appointment less than 24 hours before the time, or if my child does not arrive for an appointment, I will be liable for the cost of that appointment.
- 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.
- I agree that it is my responsibility to submit receipts/statements from the practice to be reimbursed by my medical aid, and that, the practice is not responsible if my medical aid fails to reimburse me.
- I understand that any psychotherapy/assessments are purely for diagnostic and treatment purposes, and can therefore not be used forensically, in other words in court.
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. Annelene Naidoo will make available credit and debit card facilities to make this payment process possible.
The banking details are as follows:
Bank : First National Bank
Account : Annelene Naidoo
Branch Name : Northgate
Branch Code : 256755
Type of Account : Current/Cheque Account
Account Number : 62362716270
Reference : <Your Childs Full Name>
If my child’s 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.
I understand that Annelene Naidoo may suspend therapy until all outstanding accounts are settled in full.
I understand that this practice makes use of smeMetrics billing software and that my invoices, statements etc will be generated using this software.
I have read and understand the above mentioned policies and I am willing to allow my child to continue with the assessment/psychotherapy.
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.
PROCESSING OF PERSONAL INFORMATION (POPI)
Appointments are recorded using your initials and/or first name on a password-protected electronic or hardcover diary. I need to collect and process the above and any other relevant personal information about you, including but not limited to session records/notes and communications/correspondence, that is required to provide psychotherapy services, as per HPCSA regulations and the Protection of Personal Information Act No. 4 of 2013 (POPIA).
This information will only be used for the purposes for which it was collected (providing psychotherapeutic services); the provision of such services may not be possible should you not provide this information or fail to inform me of changes or updates.
Your information will be securely stored in physical and/or electronic forms and I will review security safegurads on an ongoing basis to ensure that your information is kept safe and confidential. I may disclose your information to service providers who are involved in or enable the delivery of services to you, such as medical schemes or other health care professionals, where this is in service of your treatment and where such third parties comply with the privacy requirements as regulated by POPIA.
This may include processing and sharing information for the purpose of collecting unpaid debts. The above mentioned third parties include email and text message service providers (e.g., Gmail and webmail) and cloud storage providers (i.e., Dropbox, Google Drive and/or One Drive) who may be located outside of South Africa.
Relevant password protections will be in place to secure your information stored on these virtual platforms and I will take all reasonable steps to ensure that the privacy protections that such third parties have in place comply with the conditions of POPIA. Where specific requests are received to disclose information contained in your records (e.g., medical aid audits), a separate consent to disclosure form detailing the particulars of this request will be provided to you.
You have the right to request that I update, correct, or delete your personal information using the relevant forms as set out in POPIA (Form 1 and Form 2). These can be requested directly from me. As per the Protection of Access to Information Act (PAIA) and the processes outlined in the PAIA manual for this practice, you have the right to request a copy of the personal information that I hold about you, the copying and provision of which may be subject to payment of a legally allowable fee. The PAIA manual and Form C for requesting information can be found on the practice website or requested directly from me.
The responsibility for compliance with POPIA and PAIA lies with the registered Information Officer for this practice, Annelene Naidoo