Izaan De Wet New Patient Registration Minor

Izaan de Wet New Client Registration

for a minor 14years and younger
Please take a moment to read the following important Practice Procedure and Guidelines:

Izaan de Wet works within Dr Serahni Symington’s practice, and Dr Symington will remain closely involved throughout the process. However, the counselling sessions will take place with Izaan.

Izaan will begin with an Intake Session with the parent(s)/guardian, either in person or via Zoom. After that, your child will attend 4 counselling sessions at the practice.

These sessions take place every second week and are followed by a Feedback Session with the parent(s)/guardian, either in person or via Zoom.

✅ Total sessions: 6 x 45 minutes

Please note:
The first and last sessions are with the parent(s)/guardian only. Children should not be brought to these consultations. These sessions are important to discuss your concerns, gather background information, and plan the counselling process.

You will receive an email reminder the day before your appointment.

The questions are in English — you are welcome to answer in Afrikaans.
Client Details

PLEASE COMPLETE THE FOLLOWING INFORMATION.
Name of Child*

First NameLast Name
Nickname
Date of Birth*

DayMonthYear
Gender
If attending school which Grade
Name of school
In short describe the reason for the visit.
If sensitive leave blank
Are the child’s parents or legal guardians divorced or separated?
Please note that consent from both parents/legal guardians may be required before counselling can commence. A consent form will be sent if applicable.
Mother's name*

First NameLast Name
Mobile*
Format: (000) 000-0000.
E-mail*
example@example.com
Should this E-mail receive appointment reminders?*
Occupation
Father's name*

First NameLast Name
Mobile*
Format: (000) 000-0000.
E-mail*
example@example.com
Should this E-mail receive appointment reminders?*
Occupation
Reffered by
Please list any additional E-mail address that need to receive appointment reminders.
example@example.com
Zoom intakeIn Person intake

APPOINTMENTS AND PAYMENTS
Booking details—everything is conveniently done online.

Rates 2026

Counselling | Play Interventions | Intake | Feedback
R800 per session

Telephone Calls 15min
R250

Fees and Medical Aid – Please Read

Please note that Dr Serahni Symington’s practice is not contracted to any medical aid. At this stage, PMB (Prescribed Minimum Benefits) does not cover counselling, as it does not fall within the psychology PMB category.

This is a cash practice, and fees are charged at private rates (not medical aid tariffs). Payment is due on the day of the appointment. You are welcome to submit the invoice to your medical aid afterwards for possible reimbursement.

No further sessions will be scheduled while fees remain outstanding.
Person Responsible for Account:
Full Names and Surname*

First NameLast Name
ID number *
Email*
Invoices will be emailed.
Mobile*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
RATES AND CANCELATION POLICY

R800 Counselling | Play Interventions | Intake | Feedback | Parent Guidance

The next session will not commence unless the account has been settled.

All appointments should please be cancelled or changed via your unique booking link 24HOURS PRIOR TO YOUR APPOINTMENT.

Should it be less than 12 hours kindly send your cancellation via email: admin@drserahnisymington.co.za

Failure to adhere to this will result in the payment of the full consultation fee.
Your understanding in this regard is much appreciated.
Signature*
Date*

DayMonthYear
Date
Should be Empty:

Izaan de Wet New Client Registration

Client Details

APPOINTMENTS AND PAYMENTS

Person Responsible for Account: