1. I agree to the following:
The psychologist may disclose confidential information:

• Only with the permission of the client concerned;
• When permitted by law to do so for a legitimate purpose, such as providing a client with the professional services required;
• To appropriate professionals and then strictly for professional purposes only;
• To protect a client or other persons from harm;
• To obtain payment for a psychologist service, in which instance disclosure is limited to the minimum necessary to achieve that purpose;
• In terms of a statutory provision. The psychologist shall, in terms of any relevant law or by virtue of professional responsibility, report the abuse of any child or vulnerable adult.

2. I grant the therapist permission to use the data obtained (which will be anonymous and confidential) for research and training purposes.

3. All data will be stored for a period of 6 years, as from the date on which you cease therapy with the psychologist, as per HPCSA requirements.

I agree to the verbal contract between my therapist and myself regarding the therapeutic interventions needed and agreed upon.

I consent to the treatment and diagnoses as suggested by Elonie De Klerk, Marni Hattingh or Sonet Smit after consultation.

Crises Management:
In case of any harm to myself and/or if a crisis occurs during a session, I hereby give permission for the psychologist to contact the following person in order to obtain the necessary support:

Written Documents
Written reports/referral letters will not be provided unless formally requested 2 weeks in advance and other certificates (sick notes), must be requested 24 hours in advance. Additional costs may apply.

Communication:
I understand that if I choose to communicate with the psychologist via email, WhatsApp, or any other electronic media, that these forms of communication are not completely confidential, due to hackers and systems administrators. The psychologist will however do her best to ensure the confidentiality of any communication.

Social Media Policy:

1. The client acknowledges and understands that to maintain a professional relationship, it is unethical for the psychologist to engage with the client over social media.
2. The psychologist will not accept any invitations on any social media platforms, which include but are not limited to the following; Facebook, Twitter, Instagram, Snapchat, Wechat etc.
3. The psychologist reserves the right to remove any client or prospective client as "friend" or "follower" on any social media platform.
4. The psychologist reserves the right to take any legal action against a client or prospective client regarding any defamatory or discriminatory statements made on any social media platform about the psychologist or the practice. The legal action encompasses both civil and criminal proceedings.

Legal Recourse:
We are registered as Psychologists with the Health Professions Council of South Africa (HPCSA) and our professional behaviour is governed by this regulatory body. Please note that if you are not located in South Africa then any legal recourse will only be available in South Africa. You can verify our registrations with the HPCSA at the following link: https://hpcsaonline.custhelp.com/app/i_reg_form

Acknowledgement and consent
I/we the undersigned, acknowledge that I/we have had the opportunity to carefully read this document, to ask, and have answered any questions or concerns I/we have about the document or arising from it. I/we further acknowledge that I/we have read and understood the information contained in this document, undertake to adhere to them, and that it records my/our informed consent.