Welcome to my Practice

This document contains important information about the professional mental health services that I
offer, as well as the terms and conditions applicable to the provision of mental health services. When
you sign this document, it will represent an agreement between us. I will gladly discuss any questions
you may have about this agreement at your first session, and you can request a copy from me at any
time.

INFORMED CONSENT FOR SERVICES TO BE RENDERED (PSYCHOTHERAPY)

As a registered Clinical Psychologist, I follow an integrative psychotherapy approach, meaning that I draw from more than one theoretical approach to psychotherapy. This flexible approach ensures that the psychotherapy is tailored to your individual health care needs. After the initial consultation, we will mutually discuss your treatment needs. A successful therapeutic relationship between us depends, amongst other things, upon mutual trust. To contribute to this trust relationship, I will orally provide you with sufficient information for you to make continuously informed decisions about the treatment I provide. In turn, it is your duty to continuously enquire about anything regarding the treatment that you wish to know or do not understand.

As therapy by its nature requires you to discuss events that may be uncomfortable or even painful, you may experience some degree of discomfort, anxiety, and other negative emotions such as guilt, frustration, and regret (to mention but a few). As your therapist I will attempt to guide you through this process, and make such discussions as comfortable as possible, understanding that this may take some effort from your side and may require multiple sessions to address. Initially, you may feel as if things have worsened, largely because of such being discussed and addressed. With time this may improve, and you may feel more relaxed and inclined to engage on matters which initially unsettled you. Psychotherapy may be beneficial in that it may improve your personal relationships, general wellbeing, emotional stability, and mental health. There are, however, no guarantees in this regard, and each person may respond differently to such. The benefits are largely dependent on your individual efforts to address such, and our mutual effort in working to address such. To be most successful, you will have to work on things we discuss – outside of sessions as well.

Receiving treatment from me is always voluntary and you can refuse treatment at any stage.

Should you wish to make use of your medical aid for payment purposes, I will have to provide an “ICD10” code to enable you to claim. This ICD-10 code is a description of my clinical diagnosis of your psychological condition. I will orally explain to you the meaning of the ICD-10 code if you are not familiar with it. It is your duty to timeously enquire about anything regarding this ICD-10 code that you wish to know or do not understand. Please note that I do not have control over the management and utilization of your ICD-10 information by your medical aid. I encourage you to ensure that you are aware of your medical aid’s rules in so far as the confidentiality of this information is concerned.

Telehealth consultations (Online therapy)

With the present COVID-19 pandemic in mind, telehealth consultations provide an important social distancing safety precaution.

Telehealth consultations have limitations in that there is no in-person face-to-face interaction. The result is a lack of important visual and audio cues in the therapy process. Telehealth consultations are not an appropriate medium when you are in crisis and/or experiencing suicidal or homicidal thoughts. Face-to-face therapy is recommended in such cases.

Should I, at any stage during our therapeutic sessions, be in doubt whether telehealth consultations are in your best interest, I will advise you that we should have a face-to-face consultation to assess your situation. You can refuse to do so, but I reserve the right to cease further telehealth consultations if I believe this to be in your best interest.

Please Note The Following

~ There are risks, despite my best efforts to ensure confidentiality, that the electronic
transmission of personal information could be intercepted by unauthorized persons. For
instance, an online session can be intercepted by an unauthorized person. If this risk is not
acceptable to you, please do not commence with online therapy; and

~ It is possible that the transmission of personal information could be interrupted during a
session because of a technical failure. I might well not have any control over this possibility.

I will not record any of our online sessions unless I am of the view that the recording of sessions will benefit your therapy. Should this be the case, I will first seek your consent before recording a session

TERMS & CONDITIONS APPLICABLE TO THE PROVISION OF MENTAL HEALTH SERVICES

Cost of Treatment & Payment ::

The consultation fee for a psychotherapy session is R1100 per 45 – 50 minute session, which is revised annually. These rates fall within the scale of benefits recommended by PSYSSA (Psychological Society of South Africa).

The first session is payable upfront via EFT or directly after the session by cash or credit/debit card.

The Practice’s banking details are as follows:

Bank: Standard Bank
Account Nr: 02 33 99 333
Branch: Fourways Crossing
Branch Code: 009 953
Universal Branch Code: 051 001
Reference: Your Full Name

After the first session, there are two payment options going forward:

Medical Aid::

We can submit claims directly to your medical aid. Consultation fees are charged according to your medical aid’s approved rate for Psychotherapy. If you want to make use of your medical aid for payment of my therapeutic
sessions, it is your responsibility to find out from your medical aid if psychotherapy sessions are covered by your specific medical aid plan.

It is possible (depending on the nature of your scheme) that your medical aid will not refund you in full for my fee. It is advisable to find out what they are prepared to refund and what their ceiling limit is for treatments.

Direct Payment::

You can pay us directly after the session via credit/debit card or cash and then submit the claim to your medical aid.

This practice makes use of Healthbridge billing software.

Should you wish to make use of the Prescribed Minimum Benefits (PMB) offered by your medical aid, it is your responsibility to apply therefor. I will complete the relevant part on the form, whereafter you can do the necessary application.

Appointments are taken as confirmed when I confirm them with you via e-mail or WhatsApp. Appointments not cancelled 24 (business) hours in advance of the scheduled appointment time or not attended (including the first scheduled appointment) will be charged in full. This courtesy of cancelling in advance is essential as I could have booked another client who may need an urgent appointment or are on a waiting list. A missed session will be billed as such and not all medical aids will pay for missed sessions.

A 25% administration fee will be charged on all accounts handed over for debt collection. These fees are not refundable.

Therapy Sessions ::

The duration of a psychotherapy session is 45 – 50 minutes. If you are late for your session, you will have a shorter session and will still be charged for a 45 – 50 minute session. Sessions cannot run overtime as this will negatively impact the time of the person scheduled after you.

If you are running late for a session, please inform me. If you fail to do so, I will wait for 15 minutes, whereafter I will consider the appointment as a missed session, and I may not be available at the office anymore.

Should two (2) consecutive appointments be missed, the standing appointment will be cancelled going forward and will need to be rebooked.

Communication between us ::

For administrative matters, it is best to contact me via WhatsApp or SMS (082 452 2184) or email: [email protected] as I am often not able to answer the call when I am busy in a session. I will respond as soon as possible.

If you need to discuss something before your next booked session, please book another urgent session with me. You can book 10 min, 20 min, 30 min, or 40 min sessions for urgent matters and will be charged accordingly on a pro-rata basis.

Office hours are 08h00 to 17h00 on weekdays. I am not available outside of these hours. In case of emergencies, if you are not able to reach me, please contact your general practitioner (GP) or nearest emergency room. Please make sure to obtain these telephone numbers in advance.

Indemnifications ::

Personal Safety

Whilst I take reasonable precautionary measures, I am not able to ensure your safety when visiting my practice. Thus, when entering the property (not only my offices) on which my practice is situated, you assume full responsibility for your own safety as well as those accompanying you. Neither myself, my staff, my landlord or any other persons associated with my practice can be held liable for any injury or material damage that might befall you, or any person who accompanies you, whilst on the property. To this extent, you indemnify myself, my landlord, and all other persons associated with my practice against any claim (including claims by your dependents), of whatever nature, arising out of or associated with injury or material loss suffered by you or any other person that might accompany you whilst on the property.

Damage to property

Should you in any manner damage anything on the property on which my practice is situated, you agree to reimburse the injured party fully for the expense incurred to repair the damage caused by you.

Disclosure of confidential information

I will not knowingly divulge any information regarding yourself unless you have consented to me doing so or if I am compelled by law to do so. However, I do not accept any responsibility for damage caused by a breach of information pertaining to you and you indemnify me against loss or liability that might result from such a breach of information.

Information provided in terms of the Protection of Personal Information Act, 2013

Confidentiality

The very nature of psychotherapy requires the gathering of personal information from each client and other relevant person/s (the latter being case dependent).

All personal information of clients is subject to an obligation of confidentiality by virtue of the profession under which my practice falls, as well as South African legislation and the rules of the Health Professions Council of South Africa (the “HPCSA”). All personal information provided will be treated as strictly confidential, except under the following circumstances:

• With your express consent.
• In providing information required by a client’s medical aid or other person responsible for payment of my professional fees (where applicable) to process claims for therapy provided by me. Please note that medical aids require an International Statistical Classification of Diseases and Related Health Problems Code (ICD 10 Code) that divulges my clinical diagnosis of your psychological condition and that I have no control over their management of your personal information.
• Where I am obliged to divulge information in a court of law or in terms of a statutory provision or because it is in the public interest.
• Where consultation with other mental health professionals is viewed as being necessary.
• Where you pose a danger to yourself or another person in the event of an emergency, you authorise the psychologist to contact the individual whose particulars you have provided under Emergency Contact Person and disclose any of your personal information that I deem appropriate in the circumstances.
• In the case of a deceased client, with the written consent of the next of kin or the
• executor of the deceased’s estate.

Information security

You may be advised of appointments and other administrative details via WhatsApp and/or SMS and/or e-mail.

All personal information is collected from you during consultations or, in exceptional circumstances, from other relevant persons indicated by you (and/or their guardians, where applicable).

The personal information collected by me will be used exclusively to direct your psychotherapy sessions to reach a mutually agreed-upon desired outcome. The personal information is provided on a voluntary basis. However, withholding information will likely have a negative impact on the services rendered by me.

Your personal information gathered will only be shared with persons outside of my practice after discussion with you and with your consent.

I am responsible for maintaining the security of the personal information you provide me with.

All personal information is stored in a safe environment and, where applicable, in encrypted electronic format.

All information collected will be stored for a period of 6 (six) years as from the date on which you cease therapy with me or as otherwise provided by the HPCSA. Hereafter, the information will be destroyed, again in accordance with the guidelines provided by the HPSCA.

My practice’s website is secured by means of an SSL certificate and I take reasonable measures to ensure the continued security of my website.

Should my practice experience a personal information breach, affected clients, as well as the Information Regulator, will be advised thereof as soon as practically possible.

You will be given access to your personal information only upon receipt of your express written request and/or consent, to disclose the information concerned to a person nominated in the written document.

Drafting of reports, letters, etc, for third parties, will only be done on receipt of the express written request and consent of the client/patient (or a guardian, where applicable).

Clients who are not satisfied with the way I deal with their personal information is entitled to lodge a complaint with the Information Regulator at https://www.justice.gov.za/inforeg/contact.html.

By signing this document:

1. You give your consent to me collecting, storing, and processing your personal information as indicated above.
2. You and the person responsible for payment of my accounts acknowledge and agree to all the other terms and conditions of my practice as set out above.
3. You confirm that you have read and understood the Informed Consent section above and that you consent to me providing you with the psychological services I explained to you. You confirm that:
   a. You have been informed of the nature of the treatment provided, the benefits, risks,
   costs, and consequences generally associated with this treatment. The treatment
   described above was fully, and to your satisfaction, explained to you;
   b. You understand the purpose of the treatment being rendered;
   c. You understand that you can refuse to participate in the treatment, and that you are
   willingly participating therein;
   d. You understand that the treatment itself and the results thereof are confidential but
   that it can be made known to other persons in any of the following circumstances:
   • With your express consent;
   • In so far as it might be necessary to obtain payment from your medical aid or other
   person responsible for payment for the treatment;
   • Where the therapist is obliged to divulge information in a court of law or in terms
   of a statutory provision or because it is in the public interest;
   • Where the therapist views consultation with other mental health professionals as
   necessary; and
   • Should you pose a danger to yourself or another person and disclosure of the results
   of the treatment can prevent or minimise such danger.

Single Line Text

Client's Title

Client's Name *

First

Last

Client's Email *

Client's Mobile Number *

Client's Home Number *

Client's Work Number *

Client's ID Number *

Client's Date of Birth *

Client's Age *

Name of Client's Employer *

Client's Occupation

Client's Residential Address *

Client's Postal Address

Referring Health Care Professional

Single Line Text (copy)

Responsible Person's Title *

Responsible Person's Name *

First

Last

Responsible Person's Email *

Responsible Person's Mobile Number *

Responsible Person's Home Number *

Responsible Person's Work Number

Responsible Person's ID Number *

Responsible Person's Employer *

Responsible Person's Residential Address *

Responsible Person's Postal Address

Please advise whom invoices should be submitted to: *

• To my Medical Aid
• To myself

Medical Aid Name

Medical Aid Number

Medical Aid Plan

Main Member Full Name

Main Member ID Nr

Dependant Full Name

Dependent Code

Emergency Contact Title

Emergency Contact Name *

First

Last

*Please refer to the section titled “Information provided in terms of the Protection of Personal Information Act, 2013 (Confidentiality)” contained in this Agreement. You, the client, consent thereto that I (Marina Genis) can, in the event of an emergency, contact this person and disclose to him/her any of your personal information that I deem appropriate in the circumstances.

Emergency Contact Email *

Emergency Contact Mobile Number *

Emergency Contact Home Number *

Emergency Contact Work Number

Relation to Emergency Contact Person *

Permission to submit diagnosis code to medical aid? *

• Yes
• No

Please note that should your diagnosis code not be submitted to your medical aid that the scheme may reject your claims

I have read, understood and agree to the terms related to medical aid claims. *

• Yes
• No

I understand that this practice makes use of Health Bridge billing software. *

• Yes
• No

You confirm that you have read and understood the Informed Consent section above and that you consent to me providing you with the psychological services. *

• Yes
• No

I hereby declare that the information given in this intake form is true and correct to the best of my knowledge and belief. *

• Yes
• No

I Accept all terms and conditions