PSYCHOLOGY INTAKE FORM

By signing this form, you acknowledge that you have understood and agreed to the following:

1. That you have received a copy of the terms and conditions (provided separately) and have had an opportunity to ask questions on aspects thereof that you were uncertain about.
2. To always ask, even after you have left the practice, if you were uncertain about something. You can ask the practice staff or your psychologist. If you keep quiet, the practice staff and psychologists will assume that you have understood everything and agreed with any processes, consents, policies and/or forms.
3. If you do not keep your appointment and you have not cancelled the appointment 24 hours prior to the appointment, we reserve the right to charge a consultation fee of R1320 regardless of the reason for the cancellation. As we have kept the slot open for you and could not assist another client.
4. If you are unable to reach the practice telephonically to cancel your appointment you are encouraged to send written communication about your wish to cancel your appointment via either WhatsApp, email or text. Communication received via such mediums within the cancellation period, whether read and confirmed or not by the practice will suffice as cancellation.
5. You and/or your family or other persons that come to, or make contact with, the Practice should not harass the healthcare professionals and/or staff. They must be treated with respect. If not, we are allowed by law to refuse to treat or to continue to treat you or your children. In such cases we will refer you to another practice.

I hereby give consent for the below stated terms and conditions:

Confidentiality

1. I understand that all information regarding me will be treated as medically confidential.
2. I understand that confidentiality is legally required to be breeched in instances where I prove to be in danger of harming myself, another human being or animal; in cases of apparent, suspected or potential child abuse or neglect; or in cases where a court issues a summons for records or testimony.
3. My psychologist may use forms of communication, such as messages or emails, which despite all efforts to maintain confidentiality, may not be guaranteed due to the nature of technology.
4. I understand that for my psychologist to maintain my confidentiality in non-therapeutic settings, my psychologist may opt not to greet or acknowledge me in public. My psychologist nor any members of staff of Rivonia Therapy Centre also will not accept any social media requests from me.
5. In the event that family members or other individuals make contact with the practice or psychologist requesting information or meeting concerned yourself (the client), all prescribed limits of confidentiality will be adhered to in accordance with the Health Professions Council of South Africa (HPCSA) and in accordance with the POPI Act. This means that neither the psychologist nor practice will disclose any details whatsoever regarding you, your sessions or your therapeutic content and the process that you and your psychologist have engaged in. You are in your rights to request and consent to a family session, which will only take place if you are present in that session.
6. The practice or your psychologist will only communicate with you directly and not with an individual on your behalf unless you provide the practice with your written consent to communicate with a specific indicated person. Such consent would be required to specifically indicate the individual who can be communicated with, duration that such communication is required and specifications about the content that may be discussed with such an individual.

Client Records

1. I acknowledge that client records are kept for a period of 6 years from the date of last consultation or as regulated by professional standards set out by the HPCSA and in accordance with the POPI Act.
2. I acknowledge that I am a client of Rivonia Therapy Centre and not of my assigned treating psychologist and therefore my client records remain property of this practice for the duration as set out as above. In the event that your treating psychologist may exit the practice, a request for the transference of your Personal Information may be applied for in accordance with PAIA regulations.

Supervision & Multi-professional Teams

1. Any psychological and social information regarding me may, with my permission, be discussed with a relevant multi-professional team.
2. My information may be discussed with relevant parties for the purpose of supervision, within a confidential setting, to enable my psychologist to provide me with improved therapeutic strategies.
3. I am aware that my psychologist, although fully qualified and registered, may be continuously taking on additional training to increase competency and therefore may also be receiving training within the practice.
4. My sessions may be recorded, with my knowledge and permission, by the psychologist for benefit to the therapeutic process and supervision.
5. In the event that my treating psychologist no longer is an employee of this practice, your therapeutic information may be accessed by management of this practice, who are also qualified psychologists, and your new treating psychologist in order to allow for continuation of treatment. In such an event all efforts will be made to maintain confidentiality and limit shared information.

Therapeutic Treatment

1. I agree to undergo any agreed upon necessary tests and treatment advised and explained to me.
2. I acknowledge that psychological treatment will only be provided in the capacity as agreed upon between the relevant parties. I am aware that a psychologist may not overlap between working in a legal capacity and a therapeutic capacity. This would mean that my psychologist that is treating me in a therapeutic capacity cannot provide me with a report for whatsoever legal purposes.
3. During my continuous sessions myself and my psychologist will agree upon a treatment plan, which may be adapted and changed during the therapeutic process. I hereby consent to ensure that I understand the treatment plan, risks and benefits of my therapeutic processes. Thereby agreeing to release the practice of Rivonia Therapy Centre and its associates, to the extent permitted by law, from all claims for any loss or damages suffered as a result of the treatment.
4. I hereby state that I have taken note of my treating psychologist’s qualifications and training and I consider him/her a suitably qualified person to treat me.
5. Our terms and conditions are updated on a regular basis and by continuing with therapy I consent to the terms and conditions of the Practice. If you would like a copy of the terms and conditions at any stage, please enquire at reception or visit our website.

Reports

1. In order for any reports, letters, medical aid or other applications to be disclosed, a consent for disclosure application needs to be completed as per the POPI Act and PAIA regulations as any such report, letter or application will contain my personal information.
2. A relevant psychological report about me may be submitted to applicable parties if proved necessary, with my knowledge and permission.
3. In order to maintain confidentiality, any confidential report that my psychologist sends me via email will be password protected, using my account number as the password.
4. A report will not be provided for legal purposes of whatsoever nature if the purpose of treatment is not of a legal nature and has not been agreed upon on commencement of therapeutic treatment.
5. Therapeutic reports or progress reports are not provided by the psychologist nor the practice.
6. Sick notes or any form of notes regarding time booked off from work or school is not provided by the psychologist or this practice for whatsoever reasons. However, a letter confirming a client’s appointment date and time can be provided on request.

Billing Administration & Medical Aid Claims

1. I am aware that in the event of claiming through medical aid, the psychologist will need to submit an ICD-10 code to my medical aid which will give the medical aid an indication of the condition that I am being treated for. I have the full right to know what this code will be and discuss this further with my psychologist. If I refuse for this information to be submitted as a claim to my medical aid, I will be liable for the payment of my sessions based on the card rate of the practice.
2. I am aware that in the event of claiming through medical aid the medical aid may request additional information as per their terms and conditions.
3. I authorise the practice to process my personal information in order to perform their services. Including the relevant release of any of my clinical information such as diagnostic code and other information required to process my claims or to collect outstanding balances on overdue accounts.
4. I understand that Rivonia Therapy Centre make use of the services of administrative staff, who are bound by the confidentiality agreement of the practice, and thereby agree that my personal administrative, account and communicative information may be disclosed to such staff members.
5. By us submitting to your medical aid you consent that this requires your personal information shared with your respective medical aid via either our EDI billing system (Panacea) or via paper claim to the email address provided by your medical aid.
6. By submitting to your medical aid this may mean that other members/ beneficiaries on your medical aid scheme may have access to information pertaining to your session or claim once this is submitted to your medical aid regardless of measures taken by the practice to protect your personal information.
7. In order for the practice to submit your claim to your medical aid we require proof of your medical aid membership. If such proof contains the information of other members on your medical aid card you acknowledge that you have these individuals consent to share their personal information with the practice.

Children

1. Children over the age of 14 years are required to give therapeutic consent and are entitled to the same confidentiality as that as an adult. This would mean that the treating psychologist may not disclose any therapeutic information to another party if the child has not given their consent for the psychologist to do so. As the parent or legal guardian of the child patient you acknowledge this confidentiality agreement. Parental consent for therapy is not legally required.
2. For children under the age of 14 years to attend therapy, consent from both parents is required, except in cases where one parent can prove that he/she has full legal custody of the child. We would require that both parents sign forms which will provide consent for the child to attend therapy. Therapy cannot commence until we have received consent from both parents.
3. Your psychologist will discuss the plan and structure regarding feedback on your child’s therapeutic process with you. Your psychologist may not be available for feedback outside of the agreed upon structure, your understanding of the limitations of your psychologist’s time as he/she may be attending to other clients and work hours are appreciated. Emails are preferred; however, it may not be possible to respond immediately.
4. Although your child over the age of 14 and is required to give therapeutic consent as per clause a), in accordance with the POPI act a legal parent or guardian would be required to give consent for non-therapeutic gathering and disclosure of information.

Inpatient Treatment

1. I acknowledge that if I am treated at an inpatient facility or hospital that my confidentiality will be maintained, and with my permission discussions can be held with multidisciplinary treating practitioners.

Sessions via Technology

1. In the event that I choose to attend therapy using a form of technology such as Zoom, Skype, Facetime, WhatsApp calls, video calls, or via a phone call, I understand that my psychologist will schedule an appointment time with me and will provide such a service in a confidential setting and provide the service to the best of his/her capabilities. I acknowledge that potential technical difficulties may be experienced, and Rivonia Therapy Centre will not be held liable for diminished levels of service due to such technical factors.
2. In the event that I require therapy using a form of technology as stated above I would be responsible for ensuring that I am in a confidential setting within which the session would be conducted.
3. Your psychologist reserves the right to terminate sessions in the event that your environment in not confidential, in accordance with the POPI Act and HPCSA regulations this will be done to protect your personal information and confidentiality.
4. You will be responsible for ensuring that the application and any required software is downloaded and that you have access to the telehealth platform. Please be aware that clients are responsible for any costs incurred in relation to the provision of their own software, hardware and data usage associated with telehealth services.
5. Telehealth services requires clients to have a secure WIFI or internet connection and a working webcam and audio on their device.
6. Clients should be aware that misunderstandings may occur due to connection problems causing image delays or less than optimal image quality. Teleconferencing generally limits the amount of non-verbal information exchanged between your treating psychologist and clients and as a result, misunderstandings may occur. Clients are asked to please have patience with the process and clarify information if they think their treating psychologist has not understood them well and to also be patient if their treating psychologist asks for periodic clarification.
7. In case of emergency your treating psychologist may need to be able to contact support people known to you within your local area. Accordingly, clients will be asked to provide the names and contact details of two people known to them before the initial session. By providing your psychologist and the practice with the contact details of such individual’s, you acknowledge that you have gained their consent to share their information with us.
8. Please note that your treating psychologist will be taking notes and at times will need to look down during telehealth sessions to record these. In accordance with legislative requirements, electronic records and paper records are kept in secure storage. Your treating psychologist will not make recordings of telehealth sessions and clients are asked to respect your treating psychologist’s privacy by agreeing not to make recordings of therapy sessions and not to use materials from therapy sessions for purposes other than therapy (e.g., posting any portion of said sessions on internet websites such as Facebook or YouTube is not permitted).
9. If there is ever a disruption of services on the internet or technical difficulties your treating psychologist will message or call you to discuss how to proceed with the session. If reconnection is not possible within 10 minutes your treating psychologist will send an email or message to schedule a new session time. You are still responsible for payment of the session if the premature termination of the session is due to technical difficulties on your end.
10. The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology. Clients are responsible for understanding the potential risks of confidentiality being breached through unencrypted email, in transit by hackers or internet service providers, lack of password protection or leaving information on a public access computer. Your treating psychologist makes every effort to keep all information confidential. Likewise, clients are asked to take responsibility for creating and using additional safeguards when the computer used to access telehealth services may be accessed by others, such as creating passwords to use the computer, keeping their email and passwords secret, ensuring they fully exit all online therapy sessions and email, and maintaining security of their wireless internet access points.

Communication with the Practice or Psychologist

1. Any communication with your psychologist between sessions or management of the practice needs to be made via email for the purpose or record keeping. Your psychologist may not be available to consult with you telephonically between sessions.
2. Records of electronic communication will be kept only for the reasonable duration in relation to the purpose of the communication. Thereafter such records will be printed and stored in your client file with all electronic copies deleted.
3. I acknowledge that my psychologist or management of the practice may not be able to respond to my email timeously due to the consultation nature of the practice.

Please take note of the following rates for 2021. Our rates have been standardized as of January 2019, regardless of medical aids. Therefore, a co-payment may be applicable should you wish the Practice to claim directly from your medical aid. These are some of the most used codes within the Practice for billing purposes.

• 30 Minutes: R770
• 50 – 60 Minutes: R1320
• 80 – 90 Minutes: R1900
• 110 – 120 Minutes: R2520

By using the services of the psychologist, you confirm that you accept the following payment terms:

Medical Aid Claims

1. If you are not the principle/main member of your medical aid you agree that the principle/main member is aware of the consultation and that they have given permission for the psychological sessions to be claimed from medical aid.
2. In order to process your claim, we are required to send a claim to your medical aid which will include personal information about you and the main member. This will include information, but not limited to, such as your name and surname, identity number and icd-10 code. By requesting your claim to be submitted you are consenting that we can share the information required for your claim with your medical aid either via our EDI system, Panacea, or via paper claim to your respective medical aid’s email address.
3. Some medical aids require pre-authorisation and/or motivation prior to treatment. Pre-authorisation or scheme approval is, according to the medical aid, no guarantee of payment. You are responsible for obtaining pre-authorisations for sessions and for providing the practice with the relevant information and documentation.
4. It remains your responsibility, and not that of the practice, to familiarize yourself with the benefits and terms and conditions associated with your chosen medical cover.
5. Should there be a shortfall in medical aid funds, or the funds become depleted, the person whose signature appears on this document will be held responsible for any outstanding amounts unless a signed letter is received from the individual listed under person responsible for account. You will be notified of any shortfall messages received by the system via SMS or email. A shortfall indicates that the system has received a message and that the medical aid may either part pay or not pay the outstanding balance. You will be notified by the Accounts Department of Rivonia Therapy Centre once this is confirmed.
6. In the event of a shortfall in medical aid funds future sessions will be required to be paid at each consultation via card or cash at the rate of the practice.
7. In the event that you request the practice to claim for your session from your medical aid, on your behalf, you are responsible for ensuring that there are sufficient funds and benefits available to claim from your medical aid prior to each session. The practice may hold you liable for any cost incurred for submitting claims rejected by the medical aid.
8. You are responsible, and not the staff of the practice, to resolve any queries you may have regarding your account with Rivonia Therapy Centre with your medical aid.
9. It remains your responsibility to inform us whether your session should be claimed via medical aid or will be paid privately. Your account will only be reverted from a private account to medical aid rates if your medical aid funds are available and upon your instruction.
10. Rivonia Therapy Centre cannot be held responsible for any errors or incorrect use of funds made by your medical aid.
11. In the event that your medical aid pays you the claimed amount that should be paid to the practice and not the practice, you are required to pay this outstanding amount to the practice immediately. Not returning this payment to the practice may be viewed as fraud and may result in the practice reporting this matter to your medical aid.
12. In the event that there is a query regarding payment of your medical aid, you give us permission to contact your medical aid to resolve such an issue on your behalf, and in doing so consent to us sharing your Personal Information with the contact person at your medical aid.
13. If you feel that your medical aid scheme should have paid your account in full, you can lay a complaint at the Council for Medical Schemes by emailing them at complaints@medicalschemes.com.

Payment Terms

1. You are responsible for any outstanding amounts on the account, including amounts not paid by a medical aid claim and any co-payments that may apply.
2. Any payments made via EFT needs to contain your Account Number as reference in order to allocate your payment to your account. We request that you use your account number as reference and not your name as this assists us in protecting your personal information as required in accordance with the POPI Act. Your reference may reflect on our bank statements, banking profile, and payment notifications we receive, in the event that you provide your name as reference you are consenting to this personal information being disclosed in instances where such banking documentation may be shared or required by third parties.
3. All outstanding amounts are due for payment immediately after a session, by either cash, card, eft or SnapScan, except for sessions claimed from your medical aid. The co-payment will also be due immediately after a session.
4. In the event that an EFT payment is made for a session, that payment needs to be made at the time of your scheduled session, and POP sent to your psychologist’s email address with your account number as the reference.
5. No Cheques, Diners Club Cards or American Express Cards are accepted as methods of payment.
6. Accounts that are charged privately will not be submitted to the medical aid due to costs that incur when submitting claims. Please submit your statements that were paid with cash or card to your medical aid yourself. Any such submissions done by us on your behalf will be charged accordingly.
7. Refunds will not be made for incorrectly paid or pre-paid amounts, whether due to medical aid or private error, and will remain as credit on your account.
8. Patients are encouraged to approach the practice immediately if they experience problems with the payment of the account.
9. Accounts are handed over for legal debt recovery after 90 days. Any costs associated with such actions will be incurred towards the person responsible for account. This may result in having a bad credit record.
10. As the adult client you will be the recipient of statements and other communication from the practice. If another individual is elected to receive our statements and communication, we require this to be requested in writing with both the client and elected statement recipient to give consent for this request.
11. If the client is a minor (under 18 years of age) the parent that has signed this form will be the statement and communication recipient unless written consent is received from the elected statement recipient.

PMB (Prescribed Minimum Benefits)

1. Certain conditions may be covered by your medical aid with PMBs (prescribed minimum benefits) and your psychologist may apply for this on your request. If you have medical aid benefits and funds available, your sessions will be claimed as a normal medical aid claim until approval for your PMB application is received and approved by the medical aid. In the event that you do not have medical aid benefits or funds available you will be responsible for the payment of your sessions until approval for your PMB application is received.
2. Applications submitted for PMBs or other benefits does not guarantee approval of such, and you remain responsible for the payment of sessions during the application process.
3. You, and not your psychologist nor the practice, remain responsible for understanding your medical aid PMB benefits, how your medical aid and specific plan assign these benefits and the medical aids conditions of payment or other conditions your medical aid may have of such benefits.
4. In the event that your medical aid approves PMB benefits you and not your psychologist, nor the practice, remain responsible for ensuring that you have PMB sessions remaining from which your sessions will be claimed from. In the event that you have run out of the number of approved PMB sessions, your session will either be claimed from your medical aid, or you will be responsible for settling sessions privately.
5. In the event that your medical aid approves joint PMB benefits for psychology and psychiatry you remain responsible to be informed of how many of PMB sessions you have remaining.
6. You acknowledge that your medical aid may require that you reapply for PMB benefits every year, regardless of whether you had sessions remaining for the previous calendar year.
7. In the event that you request a PMB application to be made, please allow for at least a week for your psychologist to submit your application.
8. It remains your responsibility to be aware of any implications that a PMB application may have. Examples of such implications may be limitations to insurance applications.

Sessions via Technology

1. In the event that you request a session using a form of technology and will be responsible for the payment, such a payment needs to be made at the time of your scheduled session, and proof of payment emailed to Rivonia Therapy Centre at your psychologist’s email address with your account number as reference.
2. In the event that you have outstanding fees from previous sessions the practice reserves the right to postpone any future dated sessions up until such a time after which your payment has been received.

International Medical Aids

1. International medical aids are not accepted by the practice if the practice is not registered at the specific international medical aid and will require you to settle the full applicable fee and submit the claim yourself to your international medical aid.

Forex Payments

1. Any payments made to Rivonia Therapy Centre in foreign currency will be charged inclusively of the additional forex bank charge. You will therefore be responsible for the session rate, as well as any additional costs associated with the forex payment.

Third Party Payments

1. Rivonia Therapy Centre will not accept payment from a third party (such as a company or an individual paying on behalf of another) without a written, signed letter from the third party stating the number of sessions that they have agreed to, what their expectations of the sessions would be (such as report) and a commitment to pay following each session or ahead of each session. Additional charges may occur due to report writing or administrative tasks that are linked to such payments. Including and not restricted to the costs incurred and time required to acquire requested documentation.
2. Rivonia Therapy Centre will not be involved in any payment agreements between parties for whatsoever reason.
3. Rivonia Therapy Centre reserves the right to charge for any additional documentation and the time spent acquiring such requests by a third party due to documentation requirements, in order to receive payment.

Rates

1. Rates are charged according to the duration of the scheduled session or attended session if the latter surpasses the former.
2. Medical aid rates are determined by the individual medical aids; however, we have standardized our fees as of January 2019. Therefore, a co-payment may be applicable and is payable directly following each consultation.

Late Cancellations

1. The full applicable fee is payable for all consultations not cancelled nor met within 24 hours before the scheduled appointment date and you will be charged for consultations not met regardless of the reason for cancelling the session. Such a session will be charged at the card rate and not claimed through your medical aid. The rate for 2021 is R1320.
2. Rescheduling of appointments in less than 24 hours before the scheduled session will be charged as a late cancelation, see point a).
3. As it is difficult to determine when clients have valid or unexpected reasons for cancelling their appointment within 24 hours. As such, the sessions will be charged for regardless of the reason. This includes car troubles, traffic difficulties, forgetting an appointment, sickness and death in the family, etc.

Appointment Reminders

1. The practice sends out appointment reminders via either SMS or email, by providing your contact details you are consenting to receiving these reminders. In the event that you do not wish to receive these reminders you may withdraw your consent by informing the practice.
2. While the practice sends SMS reminders, the responsibility of keeping appointments is that of the client. If a client does miss or cancel a session in less than 24 hours, it will be charged for and not receiving an SMS reminder does not qualify as a valid excuse.

Reports, Letters and Assessments

1. Any reports, motivational letters or forms requested will incur a fee which will be charged for according to the duration spent on compiling the report. These charges will be payable according to our card rates and not claimed through your medical aid.
2. In the event that Rivonia Therapy Centre needs to rent any assessment measure from a third party (another individual or company) in order to conduct the assessment required, the cost of the rental will be in addition to the cost of the assessment.
3. You will be required to provide written consent for any reports, letters or forms requested to be sent by the practice by completing the required consent form in accordance with the POPI and PAIA Act.

Inpatient Treatment

1. In the event that you receive therapeutic services within an inpatient facility, you are responsible for ensuring that you have acquired the authorization code necessary for payment of treatment and have provided such to Rivonia Therapy Centre.

Children

1. Please note that we do not have facilities to keep an eye on children at the practice, please ensure that you arrange someone to watch your child if you are attending a session with us, as well as fetch your child directly after his/her session. If babysitting arrangements need to be made on your behalf, you will be billed accordingly.

Termination of Therapeutic Services

1. If your account has any outstanding amounts the practice may elect to pause or stop providing therapeutic services due to non-payment, and therapeutic services may be resumed once full outstanding payment is received.
2. The practice or your psychologist may elect to terminate therapeutic services in the event that your account is not paid.
3. The practice or your psychologist may elect to terminate therapeutic services if any member of staff feels threatened by yourself or an individual known to you.
4. The practice or your psychologist may elect to terminate therapeutic services in the event that therapy progress is not being made,
5. The practice or your psychologist may elect to terminate therapeutic services in the event that the psychologist feels for whatsoever reason that a referral to another psychologist is necessary.
6. Your psychologist may terminate a session or therapeutic services in the event that you are intoxicated.

Complaints and Compliments Policy

1. You are requested to address any concerns or complaints at the time that such concerns or complaints arise directly with either the administrative staff at the practice or with your treating psychologist.
2. Any complaints or compliments that require further assistance is requested to be directed in writing to the practice via email either to reception (info@rivoniatherapycentre.co.za) or to the practice owner Cindy Strydom (cindy@crs-med.co.za) in order to allow us to resolve your complaint.
3. You undertake to first make a good faith attempt to resolve complaints and concerns with the practice. In the event that complaints are placed on social media, without attempts made to resolve such with the practice directly, you will be requested to remove your comments and/or we will respond to your social media post and in doing so may be unable to maintain your confidentiality despite all attempts to do so.

Protection of Personal Information Act (POPI)

1. We collect, treat and store your personal information for the purposes of providing therapeutic services and for billing reasons. All information is processed in a reasonable and relevant manner, as well as treated with confidentiality and in line with the POPI Act.
2. In order to keep your information up to date please continuously supply our administrative staff or your treating practitioner with your latest contact detail and ask for deletion of any information you no longer want held by the practice.
3. Clients have a right to any documentation held by the practice containing their personal information. If a client wishes to request specific information held by the practice you are required to submit an application form as per the PAIA policy. The practice reserves the right to approve or deny applications.
4. All attempts have been made to ensure that our procedures around, systems used and mediums of providing our therapeutic services are POPI compliant.
5. Our premise is monitored by CCTV cameras in the common areas. This footage is monitored and in possession of the owner of the practice and only used in instances where required, in order to align with POPI regulations.
6. Our Privacy Policy and all relevant POPI Act documentation is available on request which outlines the various legalisation and processes and policies that we follow.
7. In the event that there is a breach of your Personal Information in accordance with both HPCSA and the POPI Act, your will be contacted and informed of such in accordance with the guidelines set out by the above-mentioned regulatory bodies.