I, hereby give permission to to provide psychological services, including assessment, treatment, and consultation, in accordance with the Ethical Rules of Conduct of the Health Professions Council of South
Africa (HPCSA).

These services, which upon request will be explained to me, may include individual, group, play, marital couples and family therapy counseling, consultation and psychological testing assessment. The Therapist Clinical Psychologist reserves the right to refuse involvement in ongoing future Forensic medico-legal consultation assessment evaluation, 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 therapy these services at any time and ask for a referral.

Services and Treatment

The services provided may include individual, group, play, marital/couples, and family therapy/counselling, consultation, and psychological testing/assessment. 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 these services at any time and ask for a referral. I have been informed about alternative treatment options available to me.

Confidentiality
I understand that all information shared with my psychologist is confidential and protected by law. However, there are exceptions to confidentiality, including:

- Suspected child or elder abuse
- Threats of harm to self or others
- Court-ordered disclosure

Confidentiality may also be broken in situations where maintaining confidentiality would result in clear and imminent danger to myself or others, or as otherwise provided by law.

Forensic and Legal Processes

I understand that Jenine Smith Inc. does not participate in forensic or legal processes, including:

- Court testimony
- Expert witness services
- Preparation of forensic reports
- Participation in child custody disputes

The Therapist/Clinical Psychologist reserves the right to refuse involvement in ongoing future Forensic medico-legal consultation assessment evaluation, especially if the said was not divulged at the beginning of the therapeutic process.

Electronic Communication Disclaimer

I understand that email and other electronic communication methods are not completely secure and that my therapist/Clinical Psychologist cannot guarantee the confidentiality of such communications. By choosing to communicate via electronic means, I accept the risks involved. I may withdraw consent for electronic communication at any time by informing my therapist/Clinical Psychologist in writing.

Outpatient Services

Sessions will be booked weekly on a day and time suitable for me, unless indicated differently by my clinician. I will receive a courtesy reminder 48 hours before my session. Failure to cancel the appointment will be accepted as confirmation of attendance. I will have 12 hours to cancel, failure of which will result in being billed as usual if not attended.

Inpatient Services

As an inpatient, I understand that I will be seen daily, Mondays to Fridays. If I am unable to attend a scheduled session, I must inform the administration within 12 hours to avoid being billed for the session.

Fees and Payment

I understand that the consultation fee is payable at the end of each session, unless agreed otherwise. I also understand that my therapist/Clinical Psychologist's fee may increase periodically.

Financial Responsibility and Medical Aid Disputes

I understand that I am ultimately responsible for all fees incurred for services provided, regardless of medical aid coverage or reimbursement. If I choose to submit claims to my
medical aid, it remains my responsibility to follow up on any disputes or delays in payment. Non-payment or shortfalls by my medical aid do not absolve me of my financial obligation, and I agree to settle any outstanding amounts directly with my therapist/Clinical Psychologist.

Cancellation Policy
I understand that if my appointment is not cancelled 36 hours in advance, I will be held liable for the full consultation fee.

Complaint Procedure

If I am unhappy with my treatment, I will discuss my concerns with my therapist/Clinical Psychologist first. If necessary, I can complain to the Health Professions Council of South Africa (HPCSA).

Parental/Guardian Consent (If Applicable)

If I am signing on behalf of a minor or a dependent adult, I confirm that I am the legal guardian or authorized representative and consent to their treatment.

Consent
My signature below indicates that I have read and fully understand the contents of this Informed Consent Form/Professional Agreement and agree to its terms.