Dr Symington New Patient Registration (Child)

NEW CLIENT REGISTRATION

For Children at Durbanville Prep
Please take a moment to read the following important Procedure and Guidelines:

Intake & Feedback Sessions: (60min Tuesday's and Friday's):

The process starts with an intake session with parents only – children should not attend this session.
These sessions can be conducted in person or via Zoom.
After your child has attended four individual sessions, a feedback session will be scheduled with the parent(s), again either in person or via Zoom.

Counselling and play intervention Sessions with Your Child: (30min Tuesday's and Friday's)

Each session is 30 minutes.
Sessions take place on Tuesdays and Fridays, and your child will be taken out of class during school hours. This arrangement is made in coordination with both teachers and parents.

Billing & Communication:

You will receive an invoice on the day of the session or the following day.

Intake and feedback sessions: R1200
Individual sessions: R800

Clients who settle their invoice on the day of receipt of invoice will enjoy a R100 discount on the session fee.
Client Details

PLEASE COMPLETE THE FOLLOWING INFORMATION.
Name of Child

First NameLast Name
Nickname
Date of Birth

DayMonthYear
Gender
Grade, class and teacher
Name of school
In short describe the reason for the visit.
If sensitive leave blank
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
Martial Status
Referred by
Please list any additional E-mail address that need to receive appointment reminders.
example@example.com
Parent intake session will be via: (Very important - NO CHILDREN, intake are for the parents only)

NEW CLIENT REGISTRATION

Client Details

Person Responsible for Account