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 my 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 commited 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 form legal action/debt collection against me for not settling my account.
- I understand that overdue accounts may be claims 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.
- 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 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.