Terms and conditions

Consultations

I understand that we will have an initial consultation in which the counsellor will do an assessment. I will then discuss my financial and appointment capacity openly if we decide that we can work together. We will agree on the number and frequency of appointments at the end of the first session. 

I acknowledge that sessions are 50 minutes in duration with a 10 minute buffer time.

I am aware that consultations will be conducted in one of the following ways:

- In person at the counsellor’s office
- Online using Skype (voice or video), WhatsApp (voice or video), Google Meet (voice or video) or telephone. 
- I understand that the practice will only do therapeutic work during the face-to-face sessions and that emails or messages will not be answered unless it is in regard with the scheduling sessions. 
- Before, during or after sessions neither the counsellor or any of their servants, employees or agents will be liable for any loss, theft or damage however caused whether as a result of my goods being left in and about the counsellor’s rooms or the loss or damage to any motor vehicle. The counsellor shall under no circumstances be liable for any damages or losses as a result of any negligence whatsoever either as a result of any treatment administered, advice given, or from any form of medication or treatment prescribed/ recommended to me or any of my dependents. I hereby indemnify and hold the counsellor harmless against any such claims as may arise from here. 

Online and telephonic sessions

- I acknowledge that the counsellor will wait 10 minutes from the start of the session for me to connect online. After this time the counsellor will accept that I have failed to show for my appointment. 
- I acknowledge that this service is not suitable for suicide emergencies.
- I am aware that in order to get maximum benefit from the consultation I have to ensure that I am seated in a safe, private space where I will not be disturbed during consultation. 
- I acknowledge that neither party has permission to make digital recordings of the session.

In case of technical problems:
- If I am experiencing technical problems and cannot connect with the counsellor, I will make contact with the counsellor so that we can make alternative arrangements. 
- If I fail to attend the online session and don’t make contact, I acknowledge that I  will be charged for the full session.
- If my counsellor cannot get online and connect with or connect with me, he/she will contact me to make alternative arrangements or reschedule. 

Informed consent and liability

- While fully understanding that the Counsellor will try his best to help me resolve my problem or symptoms, I fully understand that there is no guarantee that the treatment will be successful.
- I understand that memory is imperfect and research has shown that there is no guarantee that all information revealed during or after is factually accurate. However, I understand that whatever information is revealed during the sessions will be used entirely and solely for the clients’ therapeutic benefit.
- I understand that I have the right to terminate treatment whenever I wish should I feel that no or inadequate progress is being made.
- If the outcome of the therapy is not what I expected it to be, I hereby agree that I will not have legal cause of action against the Counsellor based on his professional and competent use of counselling / psychotherapeutic approaches.
- Permission is also granted by me that the information obtained during a consultation can be used for training, study purposes and publication by the Counsellor, with due regard to protecting the confidentiality of the client.
- I hereby grant permission for the Counsellor to use any modality which would be deemed beneficial in the treatment of my problem or symptoms.
- I understand that at times treatment may leave me feeling out of sorts. If advised by the Counsellor or his/her staff not to drive immediately afterwards, I understand that any failure on my part to heed this advice, will result in me being fully responsible for my actions.

Payment - Same day

- I acknowledge that I am personally responsible for the payment of my own sessions or that of my dependent.
- I acknowledge that payment will be made using a card machine at the office, EFT, SnapScan or cash. 
- I am aware that payments that are not made at the office should be made within the next 24 hours through EFT or a secure payment link. 
- I am aware that the invoice number and the date is used as reference, for confidentiality purposes, when doing EFTs. 
- I waive the right to attach any condition of any nature whatsoever to any payment.  - If a condition is so attached then the Counsellor shall be entitled to accept payment as if no condition had been attached, especially if a payment is purportedly made in full and final settlement. 

Medical aids 

- The practice is affiliated with the BHF (practice number 0942421)
- I understand that I will settle all session payments in full and then claim back from your medical aid myself
- I am aware that claims are plan and scheme dependent.
- I acknowledge that most medical aids require a referral letter from a GP that includes their practice number in order to approve claims. I am aware that if I do not have a referral letter from a GP, medical aids might not reimburse me. 
- I acknowledge that this practice will hold no responsibility to claims that cannot be reimbursed by my medical aid. 
- I am aware that the practice needs to submit ICD-10 diagnostic codes in order for the claims to be processed by medical aids, which is deemed confidential information. 
- I hereby grant permission to the practice to reflect the appropriate ICD-10 diagnostic code on my invoice/statement. 
- I am aware that I have the right to request a non-disclosure code but that the medical aid might refuse reimbursement on this. 

Cancellations, missed and late sessions 

- I am aware that I  will be expected to provide at least 24 hours’ notice if I cannot attend an appointment.
- I accept that if I cancel my appointment within the 24 hour period, the practice reserves the right to bill me for the full session. 
- I undertake to only miss appointments due to severe circumstances outside of my control. 
- If I arrive late for your session, I grant permission to  the counsellor to finish the session at the original time to make sure that following appointments are not impacted. 
- If I fail to attend your appointment without communication, I will be invoiced for the full session. 

Confidentiality

- I understand that confidentiality is an integral part of counselling and is seen as essential to building the counsellor-client relationship. I know that this ensures a sense of safety and therefore  I am encouraged to be as open and honest as possible. 
- I accept that my experiences and personal sensitive information can be disclosed with ease of mind. 
- I accept and  trust that everything that is discussed will remain completely confidential. 
- I understand that there are circumstances to which confidentiality would not apply and I agree that confidential information may be shared in instances where there is a serious risk to my life, the life of someone else or if the counsellor is asked to participate in civil or criminal court proceedings. 
- I grant permission to the counsellor to discuss my case with a supervisor or a supervision group, aware that he/she will remove all identifiable information.
- I grant permission to my counsellor to contact my emergency contact or referring doctor  if it is rationally believed that there is any risk to my life or well-being.

Electronic privacy

I acknowledge the following: 

- The practice generates invoices (including identifying and diagnostic information) using password protected software. 
- The invoices are password protected and stored in a password protected folder.
- These invoices are sent to me and my medical aid using a password protected email account. 
- The practice uses credible service providers and software for privacy and protection purposes. 
- I am aware that the practice and the counsellor cannot be held liable for breaches of confidentiality on the side of the service provider. 
- I am aware that if I am uncomfortable with electronic storage and transmission of information, I can inform the practice of my concerns and alternative arrangements will be made. 

Emergencies 

I am aware that this practice does not provide emergency services and if I feel that my life is in danger, it is my responsibility to contact emergency services like  the South African Police force, an ambulance or emergency helplines like SADAG (0800212223).

Legal recourse

- The counsellor is registered with the Health Professions Council of South Africa (HPCSA) as a Registered Counsellor (Registration: PRC0038875) and their professional behaviour is governed by this regulatory body. 
- The practice is registered with the Board of Healthcare Funders (BHF) with practice number 0942421. 
- I am aware that as a Registered Counsellor, he/she is not allowed to diagnose or prescribe any medication. With this knowledge, I will take responsibility for any decisions or actions with regards to prescription medicine.

- This form contains all the terms and conditions, representations, guarantees and warranties between myself and the counsellor and any amendment, cancellation or variation hereof shall only be effective once recorded in writing and signed by the counsellor. No latitude or indulgence granted  by  the counsellor shall be binding nor shall the same be deemed or construed to constitute a waiver or novation of the counsellor’s rights.
- No person employed by the counsellor will have any authority to vary, in any way, these terms unless so authorized in writing by the counsellor.

Informed consent

I/We the undersigned hereby give consent to the Registered Psychological Counsellor to interview, assess and treat myself and/or the child/dependent of which I am guardian/parent.

All appointments must be cancelled at least twenty-four (24) hours before the scheduled time otherwise the appointment will be charged for in full. If a Monday appointment is cancelled it must be done so by 12:00 the preceding Friday.

Should I fail to arrive for any scheduled appointment at the appointed time, I acknowledge that I will be liable for the full fee of that appointment.

I acknowledge that once appointments have been allocated to me, it becomes my responsibility to confirm all appointments in advance.

All upcoming appointments will be cancelled until payment is received for an outstanding balance.

I agree to begin counselling with Carlien Serfontein HPCSA No. PRC00338875 , Practice No. 0942421 according to the above conditions.{name}

Telehealth consent form

I hereby consent to engage in telehealth with Carlien Serfontein (PRC0038875). 

I understand that telehealth is a mode of delivering health care services, including counselling, via communication technologies (e.g. internet or phone) to facilitate counselling sessions. 

By signing this form, I understand and agree to the following: 

I have a right to confidentiality with regard to my counselling and related communications via telehealth under the same laws that protect the confidentiality of in-person sessions. The same mandatory and permissive exceptions to confidentiality outlined in the confidentiality agreement I received from my counsellor, also apply to telehealth services. 

I understand that there are risks associated with participating in telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my counsellor, that my session could be disrupted by technical failures and/or interrupted or accessed by unauthorised persons, and that the electronic storage of my session information could be accessed by unauthorised persons. 

I understand that miscommunication between myself and my counsellor may occur via telehealth. 

I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions. 

I understand that at the beginning of each telehealth session my counsellor is required to verify my full name and current location. 

I understand that in some instances telehealth may not be as effective or provide the same results as in-person counselling. I understand that if my counsellor believes I would be better served by in-person therapy, my counsellor will discuss this with me and refer me to in-person services in my area.

I understand that Carlien Serfontein (PRC0038875) is registered with the South African Health Professions Council (HPCSA) and that if I am a South African citizen residing in another country. I will forgo any legal and ethical regulations and restrictions of the resident country and agree that the HPCSA registration is sufficient as a regulating body. 

I understand that while telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that telehealth is effective for all individuals. Therefore, I understand that results cannot be guaranteed or assured. 

I understand that some platforms allow for video or audio recordings and that neither I nor my counsellor may record the sessions without the other party’s written consent. 
I have discussed the fees charged for telehealth sessions with my counsellor and agree to them. 

I understand that my counsellor will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my counsellor may not be able to assist me in an emergency situation. If I require emergency care, I will contact the relevant authorities or proceed to the nearest hospital. 

I have read and understand the information provided above, if I have anyquestions I can discuss them with my counsellor, and understand that I have the right to have all my questions regarding this information answered to my satisfaction.