New Client Registration

Is a Parent/Guardian filling out this form?

Name of Parent/Guardian

First NameLast Name

ID Number of Parent/Guardian

Relationship to the Client

Name

First NameLast Name

ID number

Email

example@example.com

Phone number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

City

Adolescent's name

First NameLast Name

Adolescent's ID number

Name

Contact nmuber

Please enter a valid phone number.Format: (000) 000-0000.

Do you have medical aid?

Medical aid scheme

Plan

Main member

Membership number

Dependant Code

Have you been approved for Prescribed Minimum Benefits Before?

Informed Consent and Professional Agreement

Please read this agreement carefully. By signing, you confirm that you understand the information below and consent to enter a therapeutic relationship with me, Willem Pieters, Counselling Psychologist.

I, {name3}{nameOf}, freely consent to receive psychological services (counselling, psychotherapy, assessment, or related support) from Willem Pieters. I may pause or end therapy at any time and I can raise concerns at any session. If I need a different kind of service, Willem will discuss referrals with me.

What Therapy Involves

Therapy is collaborative; progress can feel uneven and I may experience difficult emotions on the way to improvement.
Regular attendance and honest participation give me the best chance of benefit.

Confidentiality

Everything I share is private. Willem will only release information with my written permission or when law requires disclosure (e.g. risk of serious harm; child, elder, or disability abuse reporting).
Sessions may be audio‑ or video‑recorded only with my explicit consent for supervision or quality review. Recordings are stored securely and destroyed when no longer needed.
Anonymous case material may be used for professional learning or research; no identifying details will ever be published.

Records & POPIA

Brief process notes are kept on an encrypted, biometric‑protected device that is locked away when not in use.
Under the Protection of Personal Information Act (POPIA) I authorise Willem and trusted service partners to process my personal data for: care, administration, medical‑aid claims, and debt recovery if required.

Appointments & Communication

Office hours: Monday–Friday 08:00‑17:00. For urgent matters at those times call 071 480 0355.
Willem does not provide emergency services. After hours I will contact my GP, the nearest hospital ER, or Lifeline 0861 322 322.
Email and WhatsApp are suitable for scheduling but not for emergencies or sensitive issues.

Fees & Payment

Standard session (55 minutes) in 2025: R1 200.
If phone calls or emails about my care exceed 10 minutes in a week, pro‑rata fees apply.
I remain responsible for all fees. Balances are due within 7 days. Interest of 2 % per month applies thereafter.
Unpaid accounts older than 60 days may be handed to a debt‑collection agency, and I will be liable for collection costs.

Medical‑Aid Claims

I will confirm my psychology benefits with my scheme before treatment starts.
Claims require an ICD‑10 diagnosis code, which becomes part of my medical record and can be viewed by the principal member.
Prescribed Minimum Benefits (PMBs) are available only for certain mental‑health diagnoses recognised by my medical‑aid scheme.
Where my condition meets those criteria and the PMB application is approved, the scheme will fund a limited number of sessions from the second appointment onward; I must sign a separate PMB consent form.

Cancellations & Missed Sessions

I can reschedule or cancel without charge if I give at least 24 hours’ notice.
Late cancellations or missed appointments are billed at the full session fee.

Letters & Reports

Written reports or letters are provided on request and billed according to the time required to prepare them.

Additional Consent for Adolescent Clients (Parent/Guardian)

I confirm that I am the parent or legal guardian of {adolescentsName}, and I consent to their participation in psychological services with Willem Pieters.

I understand that, to foster trust, conversations between Willem and the adolescent are confidential. Willem will share only:
- broad themes of treatment and overall progress;
- information the adolescent explicitly agrees may be shared; or
- details necessary to protect the adolescent or others from serious harm, or as otherwise required by law (e.g. suspected abuse, suicidal intent, court order).
I may request updates, but accept that detailed session content will not be disclosed without the adolescent’s permission, unless a safety exception applies.
All other clauses in this agreement, including fees, cancellations, record‑keeping, POPIA, and my right to withdraw consent, apply equally to services rendered to the adolescent.

Acknowledgement

I have read and understood this agreement, had my questions answered, and voluntarily consent to the terms above.

Parent/Guardian Signature

Adolescent Assent:

I agree to take part in psychological services.

Adolescent Signature

Signature

New Client Registration

Next of Kin

Medical Aid Details