Informed Consent and Professional Agreement

Informed Consent and Professional Agreement

1. Benefits and Limitations of Therapy
2. Confidentiality
3. Record Keeping
4. Communication
5. Financial Agreement
6. Cancellation
7. Forensic and Psycho-legal Reporting
8. Letters and Reports

This document contains important information about my professional services and clearly defined rights and responsibilities by you as the client and myself as psychologist in order to make this a safe and effective process:

I, (Full name – will be auto-populated) _____________________________, the undersigned, hereby give consent to receiving psychological services (including but not limited to clinical/psychological assessment(s); psychotherapy/counselling and/or such other related psychological service(s) in-person or online as may be provided by Angela Deh, a Clinical Psychologist registered with the HPCSA on terms stipulated below. I understand and agree to the following terms:

1. Benefits and Limitations of Therapy
   1.1 Therapy outcomes are not guaranteed as the journey toward emotional well-being is unique for each person.
   1.2 Regular sessions and confronting troubling feelings are necessary for best results. Progress can be variable, and setbacks are normal.
   1.3 You may discontinue therapy at any time, while Angela Deh reserves the right to terminate if it is in your best interest. A referral will be provided where necessary.
2. Confidentiality
   2.1 All information collected by Angela Deh will be kept confidential on a professional basis unless it’s necessary to be shared with relevant medical professionals to implement interventions or provide feedback.
   2.2 Confidentiality can be broken when it poses a clear and imminent danger to you, Angela Deh, or others. Angela Deh is legally required to report child abuse, elder abuse, or abuse of people with disabilities. Angela Deh will first attempt to resolve the situation without breaking confidentiality.
   2.3 Sessions may be audio recorded or videotaped and may be used in supervision or to record client progress. All materials concerning clients are confidential, and every effort to maintain confidentiality is assured. Furthermore, I also understand that no demographic data is used. The Clinical Psychologist will obtain my consent before any material is recorded or presented.
   2.4 Information obtained in sessions may be used for research purposes, presented anonymously at professional meetings, and/or published in journals/textbooks. At no time will any identifying information regarding the client be used, and every effort to maintain confidentiality is assured.
   2.5 Client Consent in Terms of POPIA (Protection of Personal Information Act): I hereby consent to the processing of my personal information contemplated in the Protection of Personal Information Act No. 4 of 2013 by Angela Deh, the practice staff, and third parties with whom Angela Deh has a contractual relationship for the following purposes:
   – Treating and managing me in terms of a health professional-and-client relationship;
   – The administration of the contractual relationship between myself and Angela Deh;
   – Communicating with other persons inasmuch as it relates to my treatment and management;
   – Communicating with third parties who have undertaken to indemnify me for the costs of my treatment and management or part thereof, including medical aid schemes and their administrators where relevant; and
   – Collecting monies outstanding from the practice (A Deh Consulting PTY Ltd.).
   2.6 Online therapy may not be 100% confidential. Please use encrypted communications, preferably on password-protected devices with antivirus software, and use a private space during therapy.
3. Record Keeping
   Records of sessions will be securely stored in the form of electronic clinical and/or session notes. These records will detail the interventions used during sessions and topics discussed. The records are stored electronically on a biometric-enabled device and/or cloud server, which can only be unlocked by Angela Deh. This device is kept locked when not in use with adequate security measures.
4. Communication
   In case of emergencies, I grant Angela Deh permission to contact my emergency contacts. For emergencies outside office hours, please contact your GP, hospital emergency unit, or SADAG.ORG Crisis Helpline at 0800 567 567 for immediate assistance.
5. Financial Agreement
   5.1 I understand the payment options selected and information described in this contract. I also understand the implications of confidentiality by providing ICD-10/Diagnostic codes to medical aids should that be the required method for payment.
   5.2 Practice Fees and Charges
   5.2.1 If my therapist spends more than 10 minutes a week responding to phone calls, emails, or reporting related to my care, treatment, or management, I will be billed accordingly for this time.
   5.2.2 Failure to pay an outstanding account within 30 days of service will result in the engagement of a debt collection agency and additional fees, including 10% collection commission per installment and attorney’s fees.
   5.3 Medical Aid
   5.3.1 It is the client’s responsibility to inquire directly with their medical aid scheme before entering treatment to familiarize themselves with the scope, quantum, and annual limits for psychology service benefits available to them prior to service.
   5.3.2 Medical aid patients will be charged at the standard medical aid rate supplied by the medical aid.
   5.3.3 Practice fees and charges remain payable in full by the client or the person responsible for payment of the practice fees and charges.
   5.3.4 Should the medical aid not pay in full for services rendered, the client remains responsible for the payment of any outstanding amounts.
   5.3.5 If you qualify for (PMB) Prescribed Minimum Benefit, your diagnosis (ICD-10 code) will be shared with your medical aid. This could compromise confidentiality, as your diagnosis will be part of your medical records. The principal member can access these records.
   5.4 Cash Clients
   Clients can pay by means of cash or EFT. Please share proof of payment (POP) by WhatsApp. Clients are advised to use their invoice account number as a reference and not their names to protect confidentiality.
6. Cancellation
   6.1 If a session is not canceled at least 24 hours beforehand, the client is liable for the full fee of the session.
   6.2 Should a client arrive late, he/she will be charged for the full session.
7. Forensic and Psycho-legal Reporting
   It is important to note that my services are for therapeutic purposes only and are not intended for forensic or psycho-legal purposes. In the event of any legal proceedings arising from non-compliance with this agreement, the client will be liable for legal costs incurred.
8. Letters and Reports
   I understand that the psychologist only writes letters and reports on written request. An additional fee (depending on the amount of time spent writing the report/letter) will be charged.

I, (Full name – will be auto-populated) _____________________________, the undersigned, have read and fully understand the contents of this Informed Consent and Professional Agreement Form and hereby agree to comply with this.