Consent form for counselling services

Please read through this page and sign it at the bottom or tick the box

When you sign this document, it will also represent a legally binding agreement between counsellor and client. You may revoke this Agreement in writing at any time. That revocation will be binding on the counsellor Hanna de Kock unless I have acted in reliance on it; if there are obligations imposed on me by your company to process or substantiate claims made under you; or if you have not satisfied any financial obligations you have incurred.

COUNSELLING SERVICES
Please take note that psychotherapy and counselling often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Some sessions may include family members, depending on the presenting issue of the client. Within my practice, I treat children, adolescents, and adults.

APPOINTMENTS:
Counselling appointments are scheduled for 60-120 minutes. Extended appointments are offered when necessary. If you find it necessary to cancel a scheduled appointment, I request 24 hours’ notice in advance (unless we both agree that you are unable to attend due to circumstances beyond your control). You can cancel an appointment by sending a text message or WhatsApp or phoning 082 202 3675 and leaving a message of cancellation. Appointments missed without 24-hour notice may be billed at the regular fee. Your signature on this Agreement indicates that you agree to the terms of this policy, and you agree to make prompt payment on the charge incurred for a late cancellation appointment and/or an unattended appointment. Although I require 24 hours of notice, I would ask that you provide as much notice of a cancellation as possible to ensure smooth business operations.

FEES AND PAYMENT:
The fee for counselling and services are R600per hour (50min counselling + 10min administrative). If more than 60 days elapses without payment, unless arrangements have been made with me, I reserve the right to turn the account over to collection. In most collection situations, the only information released regarding a client’s treatment is his/her name and address, the nature of services provided, and amount due. By signing this form, you acknowledge responsibility of debt and are agreeing to a limited waiver of confidentiality to allow me to disclose the nature and frequency of my professional services to a collection agency or collection attorney, to the extent sufficient for debt collection purposes only. Such disclosure will not include any confidential information disclosed by you and will not include any professional opinions or recommendations rendered by me. Further, your signature on this form holds me faultless for any consequences, which may occur if my account is turned over to a collection agency or attorney.

MEDICAL-AID BENEFITS/REIMBURSEMENTS:
It is important to note that we do not work with medical-aid, and you will not be able to reimburse from them. We only work with cash or cards strictly after every session.

THE POPI ACT AND PATIENT RIGHTS – What is POPI?
In simple terms, the purpose of the POPI (Protection of Personal Information) Act is to ensure that all South African institutions conduct themselves in a responsible manner when collecting, processing, storing and sharing another entity’s personal information by holding them accountable should they abuse or compromise your Personal information (PPI) in any way.
The POPI legislation basically considers your PPI to be “precious goods” and therefore aims to bestow upon you, as the owner of your PPI, certain rights of protection and the ability to exercise control over:

  1. when and how you choose to share your PPI (requires your consent).
  2. the type and extent of PPI you choose to share (must be collected for valid reasons).
  3. transparency and accountability on how your data will be used (limited to the purpose) and notified if/when the data is compromised.
  4. providing you with access to your PPI, i.e., there must be adequate measures and controls in place to track access and prevent unauthorized people, even within the same company, from accessing your PPI.
  5. how and where your PPI is stored (there must be adequate measures and controls in place to safeguard your PPI to protect it from theft or being compromised).

You also have the right to object to the processing of PPI, and you have the right to lodge a complaint with the Independent Regulator (IR) as well as the contact details of the IR.

LIMITS ON CONFIDENTIALITY:
The law protects the privacy of all communications between client and a counsellor. In most situations, I can only release information about your treatment to others if you sign a written authorization form. There are other situations that require that you provide written, advanced consent. Your signature on this Agreement provides consent for the following activities:

  1. I may occasionally find it helpful to consult other health professionals and/or mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If not objected, I will not tell you about these consultations unless it is important to do so. I will note all consultations in your Clinical Record that is secure and adequately protects the privacy of your PPI.
  2. Disclosures required to collect overdue fees are discussed previously in this Agreement.
  3. If a patient threatens to harm himself/herself, I may be obligated to seek hospitalisation for him/her or to contact family members or others who can help provide protection.

There are some situations where I am permitted or required to disclose information (PPI) without either your consent or authorization:

  • to avoid prejudice to the maintenance of the law.
  • to comply with an obligation imposed by law.
  • for the conduct of proceedings in any court or tribunal.
  • in the interest of national security.
  • compliance would prejudice a lawful purpose of the collection.
  • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
  • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
  • If a client files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical reports and bills.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment without his/her authorization. These situations are unusual in my practice, but can occur:

  1. If I have reasonable cause to believe that a child has been abused, the law requires that I file a report with the appropriate governmental agency. Once such a report is filed, additional information will be required.
  2. If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to this to the appropriate governmental agency. Once such a report is filed, additional information will be required.
  3. If I determine that a client presents a serious danger of violence to another, I may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client.
  4. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
  5. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future.

PROFESSIONAL RECORDS
In pursuant legislation to the POPI Act, please be aware that I keep PPI about you, in one set of professional records, possibly two. One set constitutes your Clinical Record. It will include information about:

  1. your reasons for seeking therapy,
  2. a description of the ways in which your problem impacts on your life,
  3. your diagnosis,
  4. the goals that we set for treatment,
  5. your progress towards those goals,
  6. your treatment history,
  7. any past treatment records that I receive from other providers,
  8. reports of any professional consultations,
  9. your billing records, and
  10. any reports that have been sent to anyone, including reports to your medical aid company/insurance carrier (if applicable).

Counselling Notes are kept separate from your Clinical Record. Your Counselling Notes are not available to you and cannot be sent to anyone else, including medical aid companies without your written, signed authorization. Medical aid companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

MINORS & PARENTS
Clients under 18 years of age who are not emancipated, and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in counselling is often crucial to successful progress, particularly with teenagers, it is (at times) my policy to request an agreement from parents giving consent to relinquish their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions.

TERMINATION POLICY
All relationships have a beginning, middle, and end. This is true in friendships, business, and psychological treatment. Successful relationships are those in which the participants agree on how each phase will be handled; work together to increase the probability of success; and accept when it is time to end. Translating this philosophy to therapy, it is the position of this office that the client and therapist should mutually agree when it is time to terminate the therapeutic alliance. Ideally this time comes when the client’s treatment goals have been achieved and there is a reasonable expectation that the goals will be maintained.

If the counsellor feels that there are reasons to justify termination of treatment (and the client does not agree), the psychologist shall:

  1. Discuss the issues with the client and give the reasons for termination
  2. Attempt to correct the problem
  3. Give the client sufficient notice to assure a smooth termination
  4. Provide the client with appropriate referrals to qualified individuals
  5. Offer the client a termination session
  6. Explain the termination to the client in writing.

COVID-19 PANDEMIC

Due to the worldwide COVID-19 pandemic, a lot has changed and so is the normal running of the practice. Due to this, we have to protect you as our client and our staff members.
On 15 March 2020 the South African President Cyril Ramaphosa declared COVID-19 a national disaster. Due to the nature of the virus and the transmission mode measures have been put in place in the practice to protect the clients and the staff members.
Covid-19 has several risks that at times does not guarantee that one may not contract the virus as people may be asymptomatic. It is the client’s responsibility to notify the practice as soon as possible should they experience any flu like symptoms 24 hours before consultation to make further arrangements or to reschedule their appointments.

Our practice offers virtual consultation via zoom to try to flatten the curve by observing social distancing as requested by South African President and also to limit any contact with other clients but for our clients to consult in the in the safe space at home.

Should a client opt to choose in-person consult rather than virtual one they acknowledge that they are aware of the risk of consultations, which are beyond the counsellor’s control and the counsellor may not be held accountable for any infections. Safety precautions will be put in place to always minimize any risk such as:

  • Face mask is compulsory on entry and to be worn at all times while on premises
  • All client’s hands will be sanitized at the entrance
  • If you have any flu symptoms, please do let us know a day before for arrangements to be made
  • Please wait in your car or if a pedestrian please wait until you are called in to avoid contact with other clients.
  • No waiting area will be made available to avoid contact with other clients
  • Please allow us to open doors for you always
  • If you are accompanying a minor or a client, please wait for them in the car and only come into the offices when called in.
  • For administrative purposes, all stationery used will be sanitized before and after use
  • Our consultation rooms including chairs will be sanitized after every consultation

We do acknowledge that despite all the safety precautionary measures put in place it is still possible to contract the virus from asymptomatic persons.

POPI AGREEMENT AND CONSENT DECLARATION

YOU HEREBY DECLARE AND CONFIRM THAT YOU, AS THE PERSON/ENTITY/BODY/INDIVIDUAL/COMPANY WHO IS PROVIDING INFORMATION AND HEREIN AFTER COLLECTIVELY REFERRED TO AS THE “CLIENT”, DO HEREBY IRREVOCABLY AGREE AND UNDERSTAND THAT ANY/ALL INFORMATION SUPPLIED OR GIVEN TO THE SERVICE PROVIDER, IS DONE SO IN TERMS OF THE BELOW TERMS AND CONDITIONS AND IN TERMS OF THE AGREEMENT AND CONSENT DECLARATION.

Name
Hanna de Kock

INTERPRETATION
In this Agreement, unless inconsistent with or otherwise indicated by the context –

  1. “This Agreement” means the Agreement contained in this document
  2. “The Company/Service provider” means Name
    and includes its affiliated, holding, and subsidiary companies.
  3. “Confidential information” includes, but is not limited to:
    1. any information in respect of knowledge, formulae, processes, systems, business methods, marketing methods, promotional plans, financial models, inventions, long-term plans and any other information of the client and the company in whatever form it may be.
    2. all internal control systems of the client and the company.
    3. details of the financial structure and any other financial, operational information of the client and the company; and
    4. any agreement between the client and the company and others with whom they have business arrangements of whatsoever nature, all of which the client and the company regards as secret and confidential.
  4. “Personal information” means personal information as defined in the Protection of Personal Information Act adopted by the Republic of South Africa on 26 November 2013 and includes but is not limited to:
    1. information relating to the race, gender, sex, pregnancy, marital status, national, ethnic, or social origin, colour, sexual orientation, age, physical or mental health, well-being, disability, religion, conscience, belief, culture, language, and birth of the person.
    2. information relating to the education or the medical, financial, criminal or employment history of the person.
    3. any identifying number, symbol, e-mail address, physical address, telephone number, location information, online identifier, or other particular assignment to the person.
    4. the biometric information of the person.
    5. the personal opinions, views or preferences to the person.
    6. correspondence sent by the person that is implicitly or explicitly of a private or confidential nature or further correspondence that would reveal the contents of the original correspondence.
    7. the views or opinions of another individual about the person; and
    8. the name of the person if it appears with other personal information relating to the person or if the disclosure of the name itself would reveal information about the person.
  5. “The effective date” means the date of signature of this Agreement.
  6. “The parties” means the parties as described hereinabove.
  7. “divulge” or “make use of” means to reveal, make known, disclose, divulge, make public, release, publicize, broadcast, communicate or correspond or any such other manners of divulging of any information.
  8. “processing” means any operation or activity or any set of operations, whether or not by automatic means, concerning personal or any information, including but not limited to:
    1. the collection, receipt, recording, organization, collation, storage, updating or modification, retrieval, alteration, consultation, or use.
    2. dissemination by means of transmission, distribution or making available in any other form, or
    3. merging, linking, as well as restriction, degradation, erasure, or destruction of information.
  9. “POPI” means the Protection of Personal Information Act adopted by the republic of South Africa on 26 November 2013 and as amended from time to time.

WHEREAS IT IS AGREED THAT

All parties agree that they will comply with POPI regulations and process all the information and/or personal data in respect of the services being rendered in accordance with the said regulation and only for the purpose of providing the Services set out in the agreement to provide services.
The company (also called the service provider), all the parties to this agreement, the service provider’s employees and the client’s employees and any subsequent party/parties to this agreement acknowledge and confirm that

  • One or more of the parties to this agreement, will possess and will continue to possess information that may be classified or maybe deemed as private, confidential, or as personal information.
  • Such information may be deemed as the private, confidential, or as personal information in so far as it relates to any party to this Agreement.
  • Further it is acknowledged and agreed by all parties to this agreement, that such private, confidential, or as personal information may have value and such information may or may not be in the public domain.

For purposes of rendering services on behalf of the client, the service provider and any party associated with this Agreement and/or any subsequent or prior agreement that may have been/will be entered into, irrevocably agree that “confidential information” shall also include inter alia and shall mean inter alia:

  • all information of any party which may or may not be marked “confidential,” “restricted,” “proprietary” or with a similar designation.
  • where applicable, any and all data and business information.
  • where applicable the parties may have access to data and personal and business information regarding clients, employees, third parties and the like including personal information as defined in POPI regulation; and
  • trade secrets, confidential knowledge, know-how, technical information, data, or other proprietary information relating to the client/service provider, or any third party associated with this Agreement and (including, without limitation, all products, information, technical know-how, software programs, computer processing systems and techniques employed or used by either party to this Agreement and/or their affiliates.

By signature hereunder, all parties irrevocably agree to abide by the terms and conditions as set out in the agreement as well as you irrevocably agree and acknowledge that all information provided, whether personal or otherwise, may be used and processed by the service provider and such use may include placing such information in the public domain. Further it is specifically agreed that the service provider will use its best endeavours and take all reasonable precautions to ensure that any information provided, is only used for the purposes it has been provided.

It is agreed that such information may be placed in the public domain and by signature hereunder, all parties acknowledge that they have read all of the terms in this policy and that they understand and agree to be bound by the terms and conditions as set out in this Agreement.

It is confirmed that by submitting information to the service provider, irrespective as to how such information is submitted, you consent to the collection, collation, processing, and storing of such information and the use and disclosure of such information in accordance with this policy.

SHOULD YOU NOT AGREE TO THE TERMS AND CONDITIONS AS SET OUT IN THIS AGREEMENT AND CONSENT DECLARATION YOU MUST NOTIFY THE SERVICE PROVIDER IMMEDIATELY FAILING WHICH IT WILL BE DEEMED THAT YOU ACCEPT AND AGREE TO THE TERMS AND CONDITIONS SET OUT ABOVE.