Psychotherapy Contract for Treatment of a Minor

Welcome to my practice. This document includes important information about psychotherapy and how I work. Please read through the document and sign to indicate that you have reviewed and agree to this information.

Bookings: Booking involves reserving a specific timeslot that repeats on a weekly basis until you choose to end
therapy. Please see late cancellation policy. More or less frequent sessions can be arranged when necessary.

Confidentiality: Information that you share with my practice will be kept confidential and will not be disclosed without your consent. However, the following limits to confidentiality apply:

> Confidentiality is not guaranteed in situations that involve life threatening harm to yourself or others, nor in
situations where children are placed at risk (e.g. child abuse).
> In the event that I should be subpoenaed to testify in a legal case that you are involved in, I am obligated to
disclose information that is otherwise confidential.
> If I need to seek consultation with a colleague/supervisor regarding your psychotherapy, I will take all
reasonable precautions to disguise identifying information.
> Your invoices, PMB forms (if applicable) and any other documents I, or my personal assistant, are required to
complete and/or submit for billing/treatment purposes on your behalf will include personal information
including your diagnosis/es and/or ICD-10 code/s.
> I will liaise where necessary with other professionals involved in your care (e.g. your GP or psychiatrist)
regarding your diagnosis, treatment and progress.

Legal Reports: I do not get involved in legal and custody-related matters unless subpoenaed by court.
Patient records are kept for a period of 6 years from the date of last consultation or as regulated by professional
standards set out by the HPCSA, and will be safely disposed of/destroyed thereafter. With regards to children their
files will be kept until the age of 21 years old, and will be safely disposed of/destroyed thereafter.

Fees, Accounts and Medical Aid Claims:

Please note: Fees will increase annually at the start of each calendar year.

Please note that the first session is to be paid in cash on the date of the appointment. If this session is paid by your medical aid I will reimburse you the amount that you have paid.

I have three billing options for clients ::
Medical Aid Billing :: Option 1

I will submit your invoices to the medical aid on your behalf and claim from them directly. Should your medical aid reject the claim for any reason, we will revert to option 2( Private Billing) and you will be responsible for paying your account personally. Please note that you are responsible for keeping track of remaining Prescribed Minimum Benefit sessions. Medical aid rates are charged according to procedure code 86205. If your medical aid does not pay out for this procedure code you will be liable for the difference. Medical Aid rates generally vary between R 1000 and R 1100 per session

Please see Please see Addendum A for more information regarding Prescribed Minimum Benefits.

Private Billing :: Option 2

R1000 per session (9.1% discount). Please note the first session is to be paid in cash. You will be invoiced
after each session. Payment is due within a week of the invoice date (unless we arrange otherwise).

Cash Directly After Session :: Option 3

R850 per session (22.73% discount) (Card is R950). If you fail to pay directly after the session for whatever
reason, with the exception of a previously agreed upon arrangement, we will revert to option 2 above.

Cancellation Policy

Please let me know as early as possible if you need to cancel an appointment. I charge R850 for cancellations with less than 48 hours of notice and for missed appointments. Please be aware that medical aids will not reimburse you for cancellation fees. This applies to the first session as well.
Failure to make payment: If payment is not paid within 30 days, you will be handed over to a debt collection agency.

INFORMED CONSENT: PROCESSING OF PERSONAL INFORMATION

Appointments are recorded using your initials and/or first name on a password-protected electronic calendar 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 safeguards 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, Henri de Wet.

General

Office Hours: Monday to Thursday 09:00-18:00, but I may respond outside of these hours as well.

Electronic privacy: I utilize SMEMetrics Practice Management Software to manage bookings, create invoices and
make claims. They are a reputable company with strict privacy guidelines. Client notes are stored separately on my
password protected computer in a password protected document. I use a credible service provider for my emails,
however, I cannot be held liable for breaches to confidentiality on the side of the service provider. If you are
uncomfortable with electronic storage and transmission of your information, please let me know.

Emergencies: In the case of an emergency, I will do my best to schedule an extra session with you for as soon as
possible. However, if you feel that your life is at risk, you are responsible for going to casualty or police.

Out of session contact: I prefer that any therapeutic work (including problem solving and decision making) be kept to face-to-face sessions. If you need to contact me to change our appointment or request an additional session, email or SMS are the best way to get hold of me. I am usually able to respond to messages within a day during the week.

Psychiatric referrals: As a clinical psychologist, I do not prescribe medication. If I think medication may help you, I
will discuss a referral with you.

Termination: You are welcome to stop your sessions at any time. I will provide names of other qualified psychologists if you wish to continue psychotherapy elsewhere. For legal reasons, if we have not had a session for more than 4 weeks and we do not have any planned sessions our therapeutic relationship will be regarded as over, unless otherwise specified. If you wish to see me again after such a time we can engage in a new therapeutic relationship.

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.

If the client is under the age of 18 please note that due to the legal and financial considerations this practice
requires both parents or the legal guardians to give signed consent.

AGREEMENT
By completing this form, you agree to the Terms of Use (available on our website), Website Privacy Policy (available on our website), and terms and conditions specified in your client intake contract with Henri de Wet.