ADULT CONSENT FORM

 



    I hereby give permission to the therapistClinical
    Psychologist to interview, assess and treat myself according to the guidelinesterms mentioned below:

    These services, which upon request will be explained to me, may include individual, group, play, maritalcouples and family therapycounseling, consultation and psychological testingassessment. The TherapistClinical Psychologist reserves the right to refuse involvement in ongoing future Forensicmedico-legal consultationassessmentevaluation, especially if the said was not divulged at the beginning of the therapeutic process . I realise that psychology is an imperfect science and that a particular benefit or outcome cannot be guaranteed. I understand that in order to achieve the best results, I may need to confront troubling feelings and that I may feel worse before I start to feel better. I am seeking this treatment of my own accord and am free to discontinue therapythese services at any time and ask for a referral.

    Furthermore, I understand and agree to the following terms:

    • I have the right to confidential treatment and confidentiality will be maintained and information regarding my communication(s) with the therapistClinical Psychologist, treatment and management will be released only to qualified professionals that I have explicitly advised the therapistClinical Psychologist to release this information to. However, confidentiality can and will be broken in certain situations where maintaining confidentiality would result in clear and imminent danger to myself or others or as otherwise provided by law. Furthermore, I understand that confidentiality cannot be e n s u r e d w i t h r e g a r d s t o F o r e n s i c a n d M e d i c o - L e g a l assessmentsconsultationsevaluations,
    • The therapistClinical Psychologist is required by law to report to the appropriate authorities any suspected child abuse, elder abuse or abuse of people with disabilities. When a threat of bodily harm to others or myself is present, the therapistClinical Psychologist may break the confidentiality of communications. I understand that the therapistClinical Psychologist will make reasonable efforts to resolve these situations before breaking confidentiality,
    • Sessions may be audiotaped or videotaped and may be used in supervision or to record client progress. All materials concerning clients are confidential and every effort to maintain confidentiality is assured. Furthermore, I also understand that no demographic data is used,
    • Information obtained in sessions may be used for research purposes, presented anonymously at lectures, professional meetings and/or published in journals/textbooks. At no time will any identifying information regarding the client be used and every effort to maintain confidentiality is assured,
    • I understand that if I choose to communicate with my therapistClinical Psychologist via email, that email is not completely confidential, due to hackers and system administrators. Your therapistClinical Psychologist will, however, do her best to ensure the confidentiality of your communication and her email is password protected. Please allow 72 hours for your therapistClinical Psychologist to respond to your email. If you still have not heard from your therapistClinical Psychologist please resend your email as it is possible that it was not received. If the matter is urgent then please contact your therapistClinical Psychologist telephonically,
    • My therapistClinical Psychologist does not accept friend invitations from clients on personal social networking sites such as Facebook. Please feel free to discuss this further with his/her in therapy,
    • My therapistClinical Psychologist is required, according to the Ethical Code of Conduct governing the Profession, (the HPCSA) to keep brief records (that are maintained in a secure place) concerning our interactionscommunications. These records also include interventions used during the sessions and topics discussed. You may request a copy of your file in writing, provided that this does not cause you harm, giving your therapistClinical Psychologist a reasonable amount of time to make the copy and at a reasonable cost (not claimable from medical aids), which will be discussed with you,
    • I understand that if I choose to communicate with my therapistClinical Psychologist via email, that email is not completely confidential, due to hackers and system administrators. Your therapistClinical Psychologist will, however, do his/her best to ensure the confidentiality of your communication, and his/her email is password protected. Please allow 72 hours for your therapistClinical Psychologist to respond to your email. If you still have not heard from your therapistClinical Psychologist, please resend your email as it is possible that it was not received. If the matter is urgent, then please contact your therapistClinical Psychologist telephonically.
    • In addition to weekly consultations, I understand my therapist/ Clinical Psychologist charges this amount for other professional services I may need, though my therapist/Clinical Psychologist will break down the hourly cost if he/she works for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals I have authorised, preparation of records or treatment summaries, and the time spent performing any other service I may request of my therapist/Clinical Psychologist.
    • I understand my therapist/Clinical Psychologist's fee may increase periodically, no more than once per year. My therapist/ Clinical Psychologist will inform me in advance of any changes in fees. Fees will be discussed with me and agreed upon during my initial consultation.
    • The consultation fee is payable at the end of each session, unless agreed otherwise. Although my therapistClinical Psychologist does make every effort to claim from my medical aid, the account still remains my responsibility until settled in full by my medical aid,
    • I understand that the cost of therapy is linked to the Tariff rates as indicated by PsySSA (Psychological Society of South Africa) and is the agreed upon amount, as discussed with my therapistClinical Psychologist, which I remain responsible for, as well as all legal costs resulting from legal actiondebt collection against me for not settling my account on a client-attorney scale. I also understand that if my account is more than 60 days overdue, I will be charged interest, at a fair rate, according to the relevant legislature,
    • If my therapistClinical Psychologist spends more than 10 minutes a week responding to phone calls or emails with regards to my care, treatment or management, I will be billed
      accordingly for this time,
    • I furthermore understand that if my appointment is not cancelled 24 hours in advance, I will be held liable for the full consultation fee,
    • My therapistClinical Psychologist has my permission to release my ICD-10 code (International Statistical Classification of Disease and Health problems code) to medical aidsthird parties in order to receive payment and further treatment for myself,
    • In the case of hospital admission, longer treatment sessions and more consistent daily visits may be required and I understand that my therapist/Clinical Psychologist will arrange as indicated by the necessary treatment,
    • When indicated and after arranged with me, I understand and agree that my therapist/ Clinical Psychologist may employ other modes of communication such as Skype and/or telephone calls as indicated and with expressed purpose of effecting treatment,
    • If I am unhappy with what's happening in therapy, I understand the importance of talking about it with my therapist/ Clinical Psychologist first so that my concerns can be addressed and discussed. I understand that my therapist will approach my concerns with care and respect. If I believe my therapist/Clinical Psychologist is unwilling to listen or to respond, or if my therapist/ Clinical Psychologist has behaved unethically, I can complain to the Health Professions Council of South Africa.

    My signature below indicates that I have read and fully understand the contents of this Informed Consent FormProfessional Agreement and agree to its terms. In addition, I also understand my therapistClinical Psychologist explanations and answers to all (if applicable) of my questionsconcerns at this point. My signature indicates that I give my full consent to treatment.

    You can draw your signature with your mouse or track pad