I have requested to receive couples therapy for myself and my partner.

In therapy, we may work on issues such as:

• Effective communication patterns

• Assertiveness skills

• Listening skills

• Acceptance of differences

• Anger management

• Problems that may be pertinent to our relationship

Furthermore, I understand that:

1. The focus of couples therapy is to learn new skills to work on relationship problems;

2. Couples therapy may also involve talking about family history, important life events, past
   relationships, and any past or present emotional difficulties.

3. Couples therapy works best when communication is open and honest, and when individuals
   take responsibility for their own feelings and behaviors, rather than blaming a partner.

4. Everything in the session is kept completely confidential by the therapist. It is recommended
   that issues brought up in session remain private between the couple, rather than discussed
   with family and friends.

5. If I am having any emotional problems, in addition to the issues we have come in for, the
   therapist may recommend other kinds of help for me.

6. My therapist Clinical 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,

Additional Clauses
SESSIONS

• Normally we will meet on a weekly basis at a regular time for the 50 minutes couples
  therapy. However some clients prefer to do sessions every two weeks and should you need or want extra therapy sessions during the week, this can be arranged, but this depends on my availability. It may be helpful to attend for 6 weekly sessions, after which we can review the couples therapy process and negotiate further sessions as appropriate. However, the aim is that the counselling process is kept to a minimum number of sessions to save expenses for the client.

FEES AND MISSED OR CANCELLED APPOINTMENTS

• Fees are due at the beginning of each session by cash and couples will need to decide beforehand who will be paying for the session. Your fee for couples therapy will be R1689.00 per session. If you are contracted to medical-aid, we can claim directly. If you are more than 15 mins late, I will treat this as a cancellation without notice. Whereas scheduled breaks such as holidays will not be charged for, my normal fee will be charged for non-attendance or cancelled sessions, unless you are able to give me at least 36 hours notice.

If you are clear about what I offer, agree with the points above, and are willing to commit to this process please sign below. I look forward to working with you. My signature below indicates that I have read and fully understand the contents of this Couples Therapy Consent Form and agree to its terms. In addition, I also understand my therapist Clinical Psychologist explanations and answers to all (if applicable) of my questions concerns at this point. My signature indicates that I give my full consent to treatment.

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