New Clients Documents

All new clients are required to complete the following three forms before their first appointment: (1) New Client Informed Consent Agreement, (2) Intake Information, and (3) Accounts Contract. (You can find them below)

New client Informed Consent Agreement

Informed Consent

Confidentiality and Therapeutic Process (In person and/or online)

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.

Agree / Disagree

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

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:

Extra Documents

New online client informed consent agreement

Online Therapeutic Contract - Adults and Couples (Informed Consent)

CONSENT FORM ONLINE THERAPY
Thank you for your interest in engaging with online therapy. The following sheet provides information about online therapy which will allow you to decide whether you want to consent to psychotherapy using this medium. Please feel free to ask any questions if you need clarification.

Benefits and limitations

BENEFITS AND LIMITATIONS
Online therapy is a convenient alternative to traditional face-to-face therapy and has been shown to be effective in helping with many difficulties. However, online therapy has limitations. There is a lack of personal face-to-face interaction which can make therapy less of a relational experience. It is also not an appropriate medium if you are seriously depressed, have serious substance dependence, or you are experiencing intense suicidal or homicidal thoughts. Seeing a mental health professional face-to-face is recommended in these situations.

Technological requirements and competences

TECHNOLOGICAL REQUIREMENTS AND COMPETENCES
To engage in online therapy, you will require a device that can connect to the internet and be able to install and use the software that we agree to use for communication. A reliable high-speed internet connection (minimum 4Mbps for video) is also required. Please be aware that online therapy may utilise significant amounts of data, especially if video (300-800MB/hour) is used.

Procedures for technical difficulties

PROCEDURES FOR TECHNICAL DIFFICULTIES
Disruptions can occur when using the internet to communicate. Should our communication be disrupted by, for example, load shedding, the therapist will immediately attempt to reconnect and resume the session. However, if repeatedly unable to reconnect for 10 minutes, the session will be rescheduled to a later date once connectivity is resumed.

Billing

BILLING
Apart from the signed contract, should our session be interrupted, the fees will apply as follows:
  • 0-15 min: R255
  • 15-30 min: R510
  • 30-45 min: R765

Confidentiality

CONFIDENTIALITY
Online therapy utilises the Internet for the transmission of personal information and therefore there are increased risks to confidentiality and it cannot be guaranteed. To protect your confidentiality, we will use services that provide encryption to communicate. Please consider password protecting the devices you use and installing antivirus software to prevent access by third parties. Please ensure that you use a private environment when engaging in online therapy so that intrusions can be minimised.

By signing this, both parties agree that there will be no recordings of sessions made without explicit permission by both parties.

Consent

CONSENT
I have read the above and understand the risks associated with engaging in online therapy. I agree to participate in online therapy and comply with the policies outlined above. All other policies still apply as per the original contract; this serves as auxiliary to the original contract.
No recordings without explicit permission(Required)
I consent to participate in online therapy(Required)

Signatures

Treating therapist signature (optional)
Clear Signature
Client signature(Required)
Clear Signature
MM slash DD slash YYYY

Somatic Experience Informed Consent Agreement

Consent for the Use of Touch in Therapy

MM slash DD slash YYYY
Somatic Experiencing - Consent for the Use of Touch in Therapy

As part of my training and practice in Somatic Experiencing®, there may be occasions where intentional, therapeutic touch is offered as a supportive intervention. The purpose of this type of touch is to assist with regulation of the nervous system, grounding, and supporting a sense of safety and containment. Touch, when used, is always non-sexual, non-invasive, and clinically appropriate.

Touch is never required and is only used with your explicit consent. If touch is being considered, we will first discuss the intention, the specific type of contact, and any concerns you may have. You have the right to decline or withdraw consent at any time, including during a session, without needing to explain or justify your decision. Declining touch will not negatively affect your therapy in any way.

Consent for touch is understood as an ongoing process, not a one-time agreement. I will regularly check in with you about your experience, and we will adjust or stop any intervention if it does not feel supportive. You are encouraged to communicate any discomfort, uncertainty, or change in preference as it arises.

If at any time touch feels activating, confusing, or uncomfortable, we will pause and return to verbal processing and other non-touch-based approaches.
Consent decision(Required)

Signature

Client signature(Required)
Clear Signature
Therapist signature (optional)
Clear Signature

Contact Us

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Phone

078 869 3602

E-mail

[email protected]

Address

Unit 2 Tonquani House 6 Gardner Williams Avenue Paardevlei, Firgrove Rural, 711019 Mark St, Stellenbosch Central, Stellenbosch, 7600

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HPCSA registration number: 0137782

Practice Number: 072 7725

Resources

Solution Focused Therapy (SFT) | Ego-state Therapy | Resource Therapy | Eye Movement Integration Therapy | Brain Working Recursive Therapy | The Gottman Method