SECTION A Particulars of Child / AFDELING A Besonderhede van Kind

SECTION B Particulars of Mother / AFDELING B Besonderhede van Moeder

SECTION B Particulars of Father / AFDELING B Besonderhede van Vader

PERSON RESPONSIBLE FOR ACCOUNT /
PERSOON VERANTWOORDELIK VIR DIE REKENING

UNDERTAKING BY ALL PROSPECTIVE CLIENT AND / OR LEGAL GUARDIAN /
ONDERNEMING DEUR ALLE VOORNEMENDE KLIENTE EN / OF OUERS

The person responsible for the settlement of the account (hereafter account holder) is subjected to the conditions stipulated as follows: Die persoon verantwoordelik vir die vereffening van die rekening (hierna rekeninghouer) is onderworpe aan die voorwaardes gestipuleer as volg:

(the undersigned) confirm herewith that all services, assistance and aid provided to me by NR Psychology will be subject to the following conditions: (die ondergetekende) bevestig hiermee dat alle dienste, steun en hulp wat ek van die NR Psychology ontvang, aan die volgende voorwaardes onderworpe is:

1. I accept the above physical address as my domicilia citandi et executandi for the service of any process on me and the legal costs for any legal action against me due to my negligence of the conditions of this contract. Ek aanvaar die bogemelde fisiese adres as domicilia citandi et executandi vir die diening van enige prosesstukke gerig aan my en vir regskoste vir enige regsoptrede gehef teen my weens my verontagsaming van die voorwaardes van die kontrak.
2. I confirm that I am directly and personally responsible for the payment of any amount due. Ek aanvaar dat ek direk en persoonlik vir bovermelde rekening aanspreeklik is.
3. If notice of cancellation of an appointment is not given more than 24 hours in advance, I will be liable for the full consultation fee. Indien kennisgewing van kansellasie van ‘n afspraak nie meer as 24 uur vooraf gegee word nie, sal ek vir die volle konsultasiefooi aanspreeklik wees.

I also hereby grant NR Psychology permission, during the course of the intervention process with myself to Ek verleen hiermee ook uitdruklik toestemming aan NR Psychology om tydens die verloop van die intervensie proses met myself

1. Utilize appropriate, scientifically accepted intervention, therapeutic and/or evaluation techniques within the scope of practice of the practitioner as recognized by the Health Practitioners Council of South Africa should the practitioner consider these to be suitable methods of intervention in this case. Toepaslike, wetenskaplik erkende intervensie-, terapeutiese- en/of evaluasietegnieke binne die beroepsveld van die praktisyn volgens die Gesondheid Beroepsraad van Suid-Afrika, te gebruik, indien die praktisyn dit gepas ag in die geval.
2. Obtain and/or disseminate relevant information about the client from/to relevant persons or institutions at the absolute discretion of the practitioner. Toepaslike inligting aangaande die kliënt van/aan relevante persone of instansies te verkry of te verstrek, tot die absolute oordeel van die praktisyn.
3. Record and process client information and make video and/or audio recordings (which will be treated confidential) of therapeutic and other sessions. Kliënte-inligting te noteer en te prosesseer; en om video- en/of klankopnames te maak (wat vertroulik hanteer sal word) van terapeutiese en ander sessies.
   Signature of Mother / Handtekening van Moeder(Required)

   
   Name in Print / Naam in drukskrif(Required)
   Date(Required)

   MM slash DD slash YYYY
   Signature of Father / Handtekening van Vader(Required)

   
   Name in Print / Naam in drukskrif(Required)
   Date(Required)

   MM slash DD slash YYYY

   Client Guide for NR Psychology / Klient gids vir NR Psychology

   APPOINTMENTS

   • Your appointment time is reserved for you and is scheduled according to your therapy needs and appointment availability.
   • Please ensure that you arrive on time. Appointments can be made by contacting [email protected]
   • If you have a scheduled appointment with a therapist at NR Psychology, you will be charged the full amount for a session if you have failed to cancel 24 hours prior to an appointment, unless you cancel due to an unavoidable, verified emergency.
   • “Emergencies” are considered events beyond your control such as car accidents, hospitalizations, or illnesses of the degree to keep you away from work.
   • If you cancel two consecutive appointments, before rescheduling we will need to discuss your treatment goals and whether you are able to commit yourself to therapy at the current time.
   • If you miss 3 or more sessions without giving 24 hours’ notice or arrive 30 or more minutes late for 2 or more sessions, NR Psychology reserves the right to terminate the therapy process.
   • If at some point you decide not to continue with therapy, please call and confirm your decision, especially if you have appointments scheduled.
   • Please note that it is your responsibility to remember the time and date of your appointment.
   • If you are more than 20 minutes late, the appointment will be rescheduled.
   • As we work on an appointment basis, Neville will not be able to exceed the time set aside for a session. Should you be late for a session without making an arrangement timeously, the relevant session will be shorter. This session, though shorter, will be billed as a full session.

   PAYMENTS

   • Please let us know if you have difficulty paying an outstanding account. It is possible that we will try to accommodate you.
   • Please note that only South African money is accepted as payment, i.e. Rand.

   ONLINE SESSIONS

   Please note that the following challenges can present during online sessions:

   • Power outages
   • Poor connection services
   • Connection failure
   • Breach of confidentiality

   When you have scheduled an online therapeutic session, please make sure that the battery of the device you will be using is sufficiently charged. This will enable you to have enough time to attend a meaningful session.

   Online therapy will be provided in a safe and secure setting where only the therapist will be present, to ensure confidentiality. Please make sure that you are also in a setting where your confidentiality will be protected, also ensure all distractions in your setting are limited, allowing you to be fully present during your session. For example, attending an online session while driving will not be allowed.

   AFTER HOURS EMERGENCIES

   • In the case of emergencies after hours, public holidays, or weekends, please consult your general practitioner or nearest emergency service provider.

   QUESTIONS, CONCERNS AND CLIENT FEEDBACK

   • You are welcome to direct any questions, concerns, or feedback regarding our service delivery to Neville Robertson.
   • We offer a hybrid service delivery model, in other words, we offer face-to-face (contact) or telepractice (telecommunication via email or virtual platforms) consultations. Indicate your preference for a telepractice in your communications with NR Psychology.
   • If you choose a telepractice consultation, you will receive a link to the online appointment before the scheduled appointment.

   THERAPEUTIC AGREEMENT

   Privacy

   • NR Psychology is committed to complying with the POPI Act relating to all data collection, usage, disclosing, and general personal information aspects.
   • The treating clinician will maintain confidentiality and privacy standards during sessions and ensure safe storage of records.
   • Telecommunication, including video conferencing, may increase exposure to hacking and other online risks; as with all online activities, there is no guarantee of complete privacy and security protection, although we go to all lengths to try and ensure the safety and security of all tele-sessions.
   • You may decrease the risk by using a secure internet connection, meeting with the clinician from a private location, and only communicating using the provided secure channels.
   Please initial here / Asseblief parafeer hier(Required)

   

   CONFIDENTIALITY

   • NR Psychology may not reveal any information obtained from clients without the client’s written permission. However, the clinician has no control over any confidential information disclosed by clients outside of their offices.
   • All information shared at NR Psychology is confidential unless you sign a specific release of information with the following exceptions:
   • You express your planned intention of harming yourself or your emotional/mental state is observed by the therapist to put you at risk.
   • You express that you intend to do bodily harm to another person. (In that event, we are obligated by law to take reasonable precautions to ensure everyone’s safety.)
   • You share that you have in the past and/or present emotionally, physically, or sexually abused a minor.
   • You are a minor and you share that you are currently or have been physically or sexually abused, or the therapist determines that you are at significant risk.
   • You complain of physical symptoms, or you develop any physical symptoms while receiving therapy. You will be requested to obtain a physical examination to rule out medical basis for symptoms and allow us to speak with your physician.
   • You are currently receiving mental health services and/or are taking medication for a mental health condition, or if you require psychiatric care while receiving therapy, or if you have had previous mental health services.
   • In the above instances, the NR Psychology will take appropriate action to ensure your safety.

   RELEASE OF INFORMATION

   • I understand that I may be asked to sign a Release of Information to permit NR Psychology to speak with my physician(s).
   • When applicable, I will be asked to sign a Release of Information to permit NR Psychology to speak with my current or previous therapist(s) and/or provide mental health records.
   • I understand that I have the right to refuse to sign a Release of Information.
   • I agree per the Release of Information to a collection agency / attorneys’ firm to facilitate the collection of my outstanding account.
   • I understand that if, at any time, my therapist at NR Psychology determines that I need a different type of psychotherapy care, he/she will discuss my needs with me and transfer me to another provider where applicable and if in my best interest.
   • I give permission to NR Psychology to contact any professional source of referral (i.e. GP, psychiatrist, or other medical professional) as a professional courtesy and/or to provide update reports where indicated.

   DISCLOSURE – FORENSIC OR PSYCHO-LEGAL WORK

   • From an ethical and liability perspective, NR Psychology is not mandated to engage in any forensic work (including, but not limited to sexual abuse, court-related matters, custody cases, etc.).
   • Should any such issues arise during therapy, the current psychotherapeutic process will immediately be terminated and referred externally to a forensic expert, to protect all parties involved.
   • We do not render any form of psycho-legal work, forensic assessments, or intervention.

   THERAPEUTIC PROCESS

   • The desired results or goals may not be obtained from therapy in the time expected which may lead to disappointment/frustration.
   • During the psychotherapeutic process, some psychological pain/discomfort may arise, and sensitive, personal difficulties are addressed. The therapist may recommend referral of supplemental care in these situations.
   • If adequate progress is not made during therapy or if it becomes apparent that the therapist does not possess the necessary specialized skills to address the client’s needs effectively during therapy, the therapist may refer the client for more specialized assistance or discontinue therapy and refer to another therapist / health care professional / therapy program.
   • As everyone is unique, so is each therapeutic process. As such, the duration of your therapy cannot be determined in advance, although all processes are based on best practice principles.
   • It is recommended that you discuss this with your therapist as well as the form of treatment/intervention options and the associated risks / benefits available to you at the beginning of your therapy.
   I HAVE READ THE ABOVE, FULLY UNDERSTAND ITS CONTENTS AND ACKNOWLEDGE THE TERMS AND CONDITIONS(Required)

   I Agree and acknowledge

   I HAVE READ THE ABOVE, FULLY UNDERSTAND ITS CONTENTS AND
   AGREE TO ABIDE BY THE PROVISIONS SET FORTH ABOVE.

   Name in Print of Parent / Naam in drukskrif van ouer(Required)
   Date(Required)

   MM slash DD slash YYYY
   Signature of Parent / Handtekening van Ouer(Required)