Client Consent Form - Conscious Psychology

Sanam Naran Psychologists & Associates Inc.

Director: Ms Sanam Naran | BHF Reg No: PR0883948 | Email: consciouspsychologyza@gmail.com
Business Address: 36 Ashford Road, Parkwood, Johannesburg, 2193

Client Agreement Form

This document contains the agreement between us. It sets out the terms and conditions of our practice and provides you with essential information.

Client Details

Contact Details

Payer & Policies

Fee Consent

Final Signature

Step 1: Client's Details

Pronoun

First Name

Last Name / Second Name

ID Number

Date of Birth

Residential Address

Occupation

Employer

Preferred Language

I'm seeking therapy for the following (select up to three):

This will help us understand your needs better.

Grief & Loss

Relationship Issues

Self Development

Recent Trauma

Childhood Trauma

Abuse

Self-esteem

Anxiety

Depression

Phobias

Work Related Stress

Major Life Change

My main goals in therapy are:

Step 2: Contact Details

Phone (Home)

Phone (Work)

Cellphone Number

WhatsApp Number

Email Address

Confirm Email Address

Emergency Contact / Guardian's Details

First Name

Last Name

Cellphone Number

Email Address

Step 3: Payer Details & Practice Policies

Details of The Person Responsible For Payment ("The Payer")

Main Member's First Name

Main Member's Last Name

Phone (Home)

Phone (Work)

Cellphone Number

WhatsApp Number

Email Address

Confirm Email Address

Medical Aid Name

Medical Aid Number

Medical Aid Plan

Code

Dependent Code (if dependent)

Client's Full Names (Patient)

Residential Address

Practice Policies

Welcome to our Practice

This document contains the agreement between us. It sets out the terms and conditions of our practice and provides you with essential information. We will gladly discuss any questions you might have about this agreement, and you can request a copy from us at any time.

A successful relationship between us depends, amongst other things, upon mutual trust... (and so on)
Should any form of tests, assessment, evaluation, or diagnostic service be required... (and so on)

ICD-10 Codes

An ICD-10 code is a description of our clinical diagnosis... (and so on)

Prescribed Minimum Benefits (PMBs)

These are a set of defined minimum health benefits... (and so on)
It is important to understand the following:
- We can only apply for a condition that is specified on the official list of PMB’s
- We cannot diagnose a condition that you do not have... (and so on)
Before commencing with the application for a PMB... (and so on):
- If we use out-patient sessions for your treatment... (and so on)
- Applications made for a PMB require disclosure of your diagnosed condition... (and so on)
Should you wish to apply for a PMB, there are several ways... (and so on)

Telehealth consultations (Online consultations)

With the COVID-19 pandemic in mind, telehealth consultations... (and so on)
The negative side of telehealth consultations includes... (and so on)
Should your therapist/ health practitioner, at any stage... (and so on)
Since the internet-link between us might not always be stable... (and so on)

Cost of Treatment & Payment

At the commencement of your treatment... (and so on)
Upon your request, we will gladly provide you with a statement of account.
Appointments are taken as confirmed when we confirm it with you... (and so on)
Should we, for whatever reason, come to an alternative fee arrangement... (and so on)
For the drafting of reports or letters and the completion of forms... (and so on)
A 25% administration fee will be charged on all accounts handed over for debt collection.

Terms and conditions for payment via medical aid

Our fees will be commensurate with the annual rate specified by your medical aid...

You remain primarily responsible for payment of our fees... (and so on)
You assume full responsibility for all administrative interactions... (and so on):
- it is your responsibility to establish from your medical aid... (and so on)
- it is your responsibility to continuously keep track... (and so on)
- you must take up any rejected claim with your medical aid... (and so on)

Terms & Conditions For Cash Payments

If you do not make use of a medical aid to settle our accounts... (and so on)
At the end of the month, we will provide you with an invoice that is immediately payable. Payment is required via EFT.

Duration of Consultations

The duration of a consultation is a maximum of 50 minutes... (and so on)
If you are running late for a consultation, please inform us... (and so on)

Communication Between Us

For administrative matters it is best to contact our receptionist... (and so on)
For telehealth consultations, we recommend that Google Meet be used... (and so on)
Office hours are 08h00 to 17h00 (MST) on weekdays and 08h00 to 13h00 on Saturdays... (and so on)

Indemnifications

Personal Safety
- Whilst we take reasonable precautionary measures, we are not able to ensure your safety... (and so on)
Damage to property
- Should you in any manner damage anything on the property... (and so on)
Disclosure of Confidential Information
- We will not knowingly divulge any information regarding yourself... (and so on)

Information Provided in Terms of The Protection of Personal Information Act, 2013

Confidentiality:
- The very nature of mental health services requires... (and so on)
- The personal information that you provide, is subject to an obligation of confidentiality... (and so on):
  - with your express consent... (and so on)
  - in providing information required by your medical aid... (and so on)
  - where we are reasonably required to use the services... (and so on)
  - where we are obliged to divulge information... (and so on)
  - where consultation with other mental health professionals is viewed as necessary;
  - where you pose a danger to yourself or another person; and
  - in the case of a deceased client... (and so on)
Information Security
- You may be advised of appointments... (and so on)
- All personal information is collected from you... (and so on)
- If you are not satisfied with the way we deal with your personal information... (and so on)

Cost of Treatment

Please indicate how you wish to pay for consultations:

Using Medical Aid

Using Cash

Your Initials (Person Responsible for Payment)

I have read, understood, and agree to the practice policies outlined above.

Step 4: Consent for Payment

As stated in our agreement under the heading “Cost of treatment and payment”, our fees are as follows:

The rate per session is , this is also the fee that we charge for our consultations.

For non-medical aid purposes, our fees are .

Step 5: Final Consent & Signature

Description of the assessment, evaluation, or diagnostic service to be conducted:

I, the undersigned (Client's Full Names)

ID Number

I, the undersigned (Guardian's Full Names, if applicable)

I herewith confirm that:

The procedure described above was satisfactorily explained to me;
I understand the purpose of the procedure being conducted;
I understand that I can refuse to participate in the procedure, and that I am willingly participating therein;
I understand that the procedure itself and the results thereof are confidential but that it can be made known to other persons in specific circumstances as outlined in the policies.

By checking this box and submitting the form, I acknowledge and agree to all the terms and conditions of this agreement.

Signature of Client / Guardian:

Welcome to Conscious Psychology

Before you begin, we highly recommend creating an account or logging in.

✨ Why Create an Account?

Save & Resume: Save your consent form progress and finish it later.
Edit Anytime: Update your details easily in the future.
Therapy Journal: Access our built-in journal to track your progress and thoughts during your therapy journey.

⚠️ Crucial Step

If you choose to continue as a guest, please ensure you fill this form right to the end and click the "Submit Form" button.

If you do not reach the confirmation screen, we will not receive your consent form.

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