Prior to beginning treatment, it is essential for you to understand our approach to child therapy and agree to some rules about your child's confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under the HPCSA Ethics Code, we (Jenine Smith Inc) are legally and ethically responsible for providing you with informed consent. As we go forward, we will try to remind you of important issues as they arise.

One risk of child therapy involves disagreement among parents and/or disagreement between parents and therapist regarding the best interests of the child. If such disagreements occur, we will strive to listen carefully so that we as therapists can understand your perspectives and fully explain our own perspective. We can resolve such disagreements, or we can agree to disagree, so long as this enables your child's therapeutic progress. Ultimately, you will decide whether therapy will continue. If either of you decides that therapy should end, we (Jenine Smith Inc) will honour that decision; however, we ask that you allow us the option of having a few closing sessions to end the treatment relationship appropriately.

Therapy is most effective when a trusting relationship exists between the psychologist and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a "zone of privacy" whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. By signing this agreement, you will be waiving your right of access to your child's treatment records.

It is our (Jenine Smith Inc) policy to provide you with general information about treatment status. We will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialised skills, we as therapists will share that information with you. We not share with you what your child has disclosed to us without your child's consent. We will tell you if your child does not attend sessions.

If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviours. Sometimes these behaviours are within the range of normal adolescent experimentation, but at other times they may require parental intervention. You and your therapist must carefully and directly discuss your feelings and opinions regarding acceptable behaviour. If we ever believe that your child is at serious risk of harming him/herself or another, we will inform you.

Although our responsibility to your child may require our involvement in conflicts between the two of you, we need your agreement that involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in a session with your therapist, as confidential. Neither of you, as parents, will attempt to gain an advantage in any legal proceeding between the two of you from our (Jenine Smith Inc) involvement with your children. In particular, we need your agreement that in any such proceedings, neither of you will ask us (Jenine Smith Inc) to testify in court, whether in person or by affidavit. You also agree to instruct your attorneys not to subpoena us or to refer in any court filing to anything a Jenine Smith Inc therapist has said or done.

Note that such an agreement may not prevent a judge from requiring my testimony, even though we will work to prevent such an event. If we are required to testify, each therapist is ethically bound not to give an opinion about either parent's custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, your Jenine Smith Inc therapist will provide information as needed (if appropriate releases are signed or a court order is provided), but we will not make any recommendation about the final decision. Furthermore, if your Jenine Smith Inc therapist is required to appear as a witness, the party responsible for his/her participation agrees to reimburse his/her at the rate of R1500 per hour for time spent travelling, preparing reports, testifying, being in attendance, and any other case-related costs.

• I understand that all sessions must be paid on the day of consultation. The standard practice tariffs will apply ; I can arrange to pay the agreed upon fee on a monthly basis; or I can opt for my therapist/Clinical Psychologist to claim directly from my medical aid (medical aid rates will apply).

• 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 she works for periods of less than one hour. Other services include report writing, fee sessions, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals I have authorized, 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 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 questions concern at this point. My signature indicates that I give my full consent to treatment.

Abbreviated Contract Draft

• If you decide to terminate treatment, we have the option of having a few closing sessions with your child to end the treatment relationship properly.

• You are waiving your right to access your child's treatment records.

• We will inform you if your child does not attend the treatment sessions.

• If necessary, to protect the life of your child or another person, we have the option of disclosing information to you without your child's consent.

• If your child's appointment is not cancelled 36 hours in advance, you will be held liable for the full consultation fee.

• You agree that our role as therapists of Jenine Smith Inc is limited to providing treatment and that you will not involve us in any legal dispute, especially a dispute concerning custody or custody arrangements (visitation, etc.).

• You also agree to instruct your attorneys not to subpoena a therapist of Jenine Smith Inc or to refer in any court filing to anything he/she may have said or done.

• If there is a court-appointed evaluator, and if appropriate releases are signed and a court order is provided, we will provide general information about the child which will not include recommendations concerning custody or custody arrangements.

• If for any reason, a therapist of Jenine Smith Inc is required to appear as a witness, the party responsible for his/her participation agrees to reimburse his/her at the rate of R1500 per hour for time spent travelling, preparing reports, testifying, being in attendance, and any other case-related costs.