Sebrina Client Registration: Adolescent and Adult

NEW CLIENT REGISTRATION

For Counselling Sessions With Sebrina Schneider
Welcome! We are pleased to have you at our practice.

Sebrina Schneider offers appointments in person or online. Please indicate your preferred option when making your booking. Sessions are 45 minutes.

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

The registration form is in English; however, you are welcome to complete it in Afrikaans if you prefer
Client Details

PLEASE COMPLETE THE FOLLOWING INFORMATION.
Name

First NameLast Name
Nickname
Gender
Date of Birth

MonthDayYear
Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should this E-mail receive appointment reminders?
Occupation
In short describe the reason for the visit.
If sensitive leave blank
Please list any additional E-mail address that need to receive appointment reminders.
example@example.com
Please indicate whether your session will be in-person meeting or Zoom meeting.
This may by changed at anytime, please just inform the admin team
Referred by

APPOINTMENTS AND PAYMENTS
All bookings are made online. Our practice admin and booking system operate digitally, and we do not have a dedicated receptionist for scheduling appointments.

Rates 2026

Counselling | Intake | Feedback: R800 per session (45min)

Payment Information
Please note that Sebrina Schneider is a registered counsellor and is not contracted to any medical aid. PMB (Prescribed Minimum Benefits) currently does not cover counselling, as it is not included in the psychology PMB category.

Dr Serahni Symington Practice is a cash practice, and fees are charged at private rates (not medical aid tariffs). Payment is due on the day of your appointment, after which you are welcome to submit your claim to your medical aid for possible reimbursement.

We offer a R100 discount when payment is made on the day of your appointment. You do not need to make payment immediately after your session, but to qualify for the discount, please email your proof of payment to the practice before the end of the day. accounts@drserahnisymington.co.za

Please note that no further appointments can be scheduled if there are any outstanding fees from previous sessions.
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

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 24 HOURS PRIOR TO YOUR APPOINTMENT.

Should it be less than 12 hours kindly send your cancellation via email: accounts@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
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

NEW CLIENT REGISTRATION

Client Details

APPOINTMENTS AND PAYMENTS

Person Responsible for Account: