Book a Counselling Session

New Client Intake Form
Person to Receive Counselling
Full Name*

First Name(s)Last Name
Preferred Name:
SA ID number (or passport number if foreign citizen):*
Date of birth:*

DayMonthYear
Age:*
Age in years
Gender:*
Please Specify*
Pronouns:*
Please Specify*
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible for Account
The person receiving counselling is also responsible for the account.
Full Name*

First Name(s)Last Name
Preferred Name:
SA ID number (or passport number if foreign citizen):*
Date of birth:*

DayMonthYear
Age:*
Age in years
Gender:*
Please Specify*
Pronouns:*
Please Specify*
WhatsApp/Cell Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Case of Minors
The person receiving counselling is an adult.
Name of Caregiver 1:*
Name of Caregiver 1:
Caregiver 1 Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Caregiver 1 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Medical Aid
No medical aid available.
Medical Aid Name:*
Plan:*
Membership Number:*
Main Member Name:*
Main Member ID number:*
Name of Dependent 1:
Dependent 1 Date of Birth:

DayMonthYear
Name of Dependent 2:
Dependent 2 Date of Birth:

DayMonthYear
Name of Dependent 3:
Dependent 3 Date of Birth:

DayMonthYear
Name of Dependent 4:
Dependent 4 Date of Birth:

DayMonthYear
Emergency Contact (Friend or Relative)
Emergency Contact Name:*
Emergency Contact Number:*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?*
Please Specify Which Professional Referred You:*

Counselling Intake
Reason for seeking counselling now:*
Current medication:
Other healthcare professionals currently consulting:
Relevant medical and/or psychosocial history:*
Name:*
Typing your name here serves as your electronic signature.
Date*

DayMonthYear

Counselling Client Contract

Please read, initial and sign
The undersigned gives the counsellor permission to treat the undersigned or legal guard in their capacity as counsellor. The undersigned accepts responsibility for the account and accepts that consulting fees are charged in accordance with the fee structure of the Board of Healthcare Funders of South Africa. The practice is contracted out of medical aids and sessions are kindly requested to be settled at the time they are held. The rate for 2024 is R550 per 50 minute session or part thereof. There is an annual increase of 8% per annum effective 1 January each year. It is the client’s responsibility to liaise with medical aids for refunds and to keep up to date with available funds.
- Appointments not cancelled with 24 hours' prior notice on the business day before will be fully charged regardless of the reason for cancellation.
- Monday appointments need to be cancelled by the corresponding time on the preceding Friday and sessions the day after a public holiday on the day before the public holiday.
- Appointments are taken as confirmed at time of verbal booking; electronic calendar invites are a courtesy and have no bearing on the confirmation of appointments.
- Cancellations via email are not accepted, as they are not always received.
Initials of Client 1*
Sign your initials
Initials of Client 2 (if applicable)
Sign your initials

Cancellations are required with more than 24 hours' notice regardless of acceptance of electronic meeting requests and must be cancelled telephonically or via WhatsApp and not via email, as these are not always received. The practice number is +27 72 313 2524. Please follow up with confirmation of cancellation.

Telephone calls and emails longer than 10 minutes will be charged for. Meetings with third parties (such as partners etc.) will be charged to the undersigned even if requested by the Counsellor. In the case of minors, feedback sessions to parents are charged in full. Late-coming on the part of the client will shorten the length of the session and will be charged in full. Sessions cannot run overtime due to late-coming on the part of the client. If the account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, the Counsellor has the option of using legal means to secure payment, which may involve a collection agency or small claims court, in which case these costs will be added to the claim. The undersigned acknowledges that: the Counsellor is registered with the HPCSA; consent for counselling may be withdrawn; consultations are recorded; information regarding the counselling process may be communicated for the purpose of replying to referrals, case consultation, research and/or supervision; further limits to confidentiality exist in the case of the client being at risk to self or others, when a child is in danger and/or the court orders the Counsellor to reveal the information, and in that billing and appointments are managed by external parties such as a receptionist, billing bureaus and medical aids; the cellular phone belonging to the practice is not a confidential line and messages may be read by the practice receptionist unless specified as confidential; counselling reports are not provided regardless of circumstance; the Counsellor may claim directly from the client’s medical aid for unpaid accounts; the undersigned understands that the Counsellor uses an integrative approach which incorporates, among others, mindfulness, relaxation and the principles thereof directly and indirectly.

Why a 24-hour cancellation policy? The reason that there is a cancellation policy is because we are only able to see so many clients in a day and when a session is cancelled with limited notice, we are unable to fill that time slot with a client from the waiting list. This time therefore becomes “dead stock” and represents an unrecoverable loss to the practice. The intention is not to punish the client and of course, life happens, but a 24-hour cancellation policy ensures the healthy survival of the practice, allowing us to continue to provide a service to you, our valued clients. Thank you for your understanding!

I have read and accepted all the above terms and conditions.I accept the cancellation policy in its entirety.
I have received by email and I understand and accept all POPIA procedures.
Signed at City on this date day of 20year
Client 1 Name:*
Typing your name here serves as your electronic signature.
Client 2 Name:
Typing your name here serves as your electronic signature.
SA ID number (or passport number if foreign citizen):*
SA ID number (or passport number if foreign citizen):
(In the case of minors and couples both caregivers/partners are required to sign.)
Caregiver 1 Name:*
Typing your name here serves as your electronic signature.
Caregiver 2 Name:*
Typing your name here serves as your electronic signature.
Counsellor: Aurora Brown
HPCSA number: PRC 0042951
Practice number: 1206737
Should be Empty:

New Client Intake Form

Person to Receive Counselling

Person Responsible for Account

In Case of Minors

Medical Aid

Emergency Contact (Friend or Relative)

Counselling Intake

Counselling Client Contract