TERMS OF THE PRACTICE. INFORMED CONSENT & COUNSELLING CONTRACT

Welcome to my practice. This document includes important information about counselling and how I work. Please read through the document and Initial each page and sign to indicate that you have reviewed and agree to this information.

1.TERMS OF THE PRACTICE

1.1 Accounts are deemed to have been received five (5) days after dispatch and to be correct in all respects unless I notify theCounsellor in writing of any discrepancy or error within a further seven (7) days thereof. I undertake to pay all costs actually incurred by the Counsellor in recovering any amount due including attorney and own client charges, tracing and collection charges and any other costs incurred in proving a claim in the event of death or insolvency.

1.2 I acknowledge that I am personally responsible for the account in respect of both myself and my dependents nominated herein and it is my responsibility to submit all claims to my Medical Aid for reimbursement.

1.3 I acknowledge that my Medical Aid requires the Counsellor to submit an ICD-10 (International Statistical Classifications of Diseases and Related Health Problems – Version 10 developed by the World Health Organization for international use in the collection of morbidity and mortality information) diagnostic code in order for my claim to be processed by them. I hereby grant the Counsellor permission to reflect the appropriate ICD-10 diagnostic code on my invoice/statement. I am aware that I have the right to request the use of a non-disclosure code, but that the possibility exists that my Medical Aid may refuse reimbursement based on this.

1.4 I acknowledge that all appointments scheduled outside office hours, i.e. before 10h00 and after 22h00 on weekdays, as well asall appointments scheduled over Sundays, will be deemed to be emergency consultations. As such, and in accordance with the National Health Reference Price List for Psychological Counsellors, all emergency treatments will be subject the relevant consultation fee plus a 50% after hours fee.

1.5 The therapeutic hour consists of fifty (50) minutes counselling time and ten (10) minutes for administrative purposes. In the case of double appointments, the therapy time will be one hundred (100) minutes and twenty (20) minutes for administrative purposes.

1.6 The Counsellor shall in his absolute discretion be entitled to appropriate any amounts received from me or my Medical Aid to the payment of any amoun ts whatsoever due to the Counsellor, and any such amount shall first be deemed appropriate towards interest, costs and other charges before the reduction of capital. The Counsellor shall be entitled to cede any amount due to him to any third party and I waive any requirement of notice thereof.

1.7 Electronic privacy: I generate invoices (including identifying and diagnostic information) electronically. These invoices are password protected and stored in a password protected folder. I send these invoices to clients and medical aids using a password protected email account. I use credible service providers for both of these purposes, however, I cannot be held liable for breaches to confidentiality on the side of the service provider. If you are uncomfortable with electronic storage and transmission of your information, please let me know so that we can make alternative arrangements.

1.8 Emergencies: In the case of an emergency, I will do my best to schedule an extra session with you for as soon as possible. However, if you feel that your life is at risk, you are responsible for going to casualty or police.

1.9 Out of session contact: I prefer that any therapeutic work (including problem solving and decision making) be kept to face-to-face sessions. If you need to contact me to change our appointment or request an additional session, email or SMS are the best way to get hold of me. I am usually able to respond to messages within a day during the week.

1.10 Psychiatric referrals: As a Registered Counsellor, I do not prescribe medication. If I think medication may help you, I will discuss a referral with you.

1.11 I choose domicilium citandi et executandi for all notices and processes at the address as given herein. In the event that my telephone facsimile number or e-mail address is indicated I agree that unless the contrary is proven, any notice sent by telephone facsimile or e-mail is deemed to have been received on the day of dispatch thereof. It remains the responsibility of the client to advise the Counsellor of any changes in contact details.

1.12 Neither the Counsellor nor any of his servants, employees or agents will be liable for any loss, theft or damage however caused whether as a result of my goods being left in and about the Counsellor’s rooms or the loss or damage to any motor vehicle. The Counsellor shall under no circumstances be liable for any damages nor any losses as a result of any negligence whatever either as a result of any treatment administered, advice given or from any form of medication or treatment prescribed/recommended to me or any of my dependents. I hereby indemnify and hold the Counsellor harmless against any such claims as may arise here from.

1.13 This form contains all the terms and conditions, representations, guarantees and warranties between myself and the Counsellor and any amendment, cancellation or variation hereof shall only be effective once recorded in writing and signed by the Counsellor. No latitude or indulgence granted by the Counsellor shall be binding nor shall the same be deemed or construed to constitute a waiver or novation of the Counsellor’s rights. I waive the right to attach any condition of any nature whatsoever to any payment. If a condition is so attached then the Counsellor shall be entitled to accept payment as if no condition had been attached, especially if a payment is purportedly made in full and final settlement. No person employed by the Counsellor will have any authority to vary, in any way, these terms unless so authorized in writing by the Counsellor.

2.INFORMED CONSENT & LIABILITY

2.1 While fully understanding that the Counsellor will try his best to help me resolve my problem or symptoms, I fully understandthat there is no guarantee that the treatment will be successful.
Confidentiality: Information that you share with me will be kept confidential and will not be disclosed without your consent. However, the following limits to confidentiality apply:
❖Confidentiality is not guaranteed in situations that involve life threatening harm to yourself or others, nor in situationswhere children are placed at risk (e.g. child abuse).
❖In the event that I should be subpoenaed to testify in a legal case that you are involved in, I am obligated todisclose information that is otherwise confidential.
❖If I need to seek consultation with a colleague/supervisor regarding your psychotherapy, I will take all reasonableprecautions to disguise identifying information.
❖Your invoices, PMB forms (if applicable) and any other documents I am required to complete and/or submit for billingpurposes on your behalf will include your diagnosis/es and/or ICD-10 code/s.
❖I will liaise where necessary with other professionals involved in your care (e.g. your GP or psychiatrist) regarding yourdiagnosis, treatment and progress.

2.2 I understand that the Counselling session might be fully audio- or videotaped or both at the discretion of the Counsellor and that these audio- or videotapes will be kept confidential by the Counsellor.

2.3 I understand that memory is imperfect and research has shown that there is no guarantee that all information revealed during or after is factually accurate. However, I understand that whatever information is revealed during the sessions will be used entirely and solely for the clients’ therapeutic benefit.

2.4 I understand that I have the right to terminate treatment whenever I wish should I feel that no or inadequate progress is being made.

2.5 If the outcome of the therapy is not what I expected it to be, I hereby agree that I will not have legal cause of action against the Counsellor based on his professional and competent use of counselling / psychotherapeutic approaches.

2.6 Permission is also granted by me that the information obtained during a consultation can be used for training, study purposes and publication by the Counsellor, with due regard to protecting the confidentiality of the client.

2.7 I hereby grant permission for the Counsellor any modality which would be deemed beneficial in the treatment of my problem or symptoms.

2.8 I understand that at times treatment may leave me feeling out of sorts. If advised by the Counsellor or his staff not to drive immediately afterwards, I understand that any failure on my part to heed this advice, will result in me being fully responsible for my actions.

2.9 DISCLAIMER: The Counsellor and his agents and his agent’s employees do not accept or take any responsibility or liability for the safe custody of, or damages to any vehicle or articles therein, nor for any injuries or loss but not limited to any negligent act of his agents and/or employees due to any collision, fire, theft, rain, hail, or any causes whatsoever. All vehicles are parked in all respects at the risk of the parker/owner thereof and all persons entering these premises do so at their own risk. Right of admission reserved.

3.CONSENT INCLUDING MINORS/CHILDREN

I/We the undersigned hereby give consent to the Registered Counsellor to interview, assess and treat myselfand/or the Child/Dependent of which I am guardian/parent.

4.CANCELLATION FEE

4.1 All appointments must be cancelled at least twenty-four (48) hours before the scheduled time otherwise a full appointment willbe charged for in full. If a Monday appointment is cancelled it must be done so by 12h00 the preceding Friday.
4.2 Should I fail to arrive for any scheduled appointment at the appointed time, I acknowledge that I will be liable for the full fee of that appointment.
4.3 I acknowledge that once appointments have been allocated to me, it becomes my responsibility to confirm all appointments in advance.
4.4 No-shows and late cancellations (less than forty-eight (48) hours prior to the appointment time or after 12h00 the preceding Friday if my appointment is on a Monday) will charged for in full, regardless of the reason (no refund will be issued in the case of clients who have settled their account in advance), and
all upcoming appointments will be cancelled until payment is received for the outstanding balance.
4.5 Should any appointments which have been paid in advance be cancelled at least twenty-four (48) hours in advance, or in the
case of a Monday appointment, the preceding Friday by 12h00, the client will receive a full refund for the appointment, or the
payment will be carried over to the next booked appointment.

Informed Consent: I have read and understood and agree the above statements, and I have had an opportunity to ask questions about them. I agree to begin counselling with Salmaan Khader (HPCSA No. PRC 0751359, Practice No. 0033529) according to the above conditions, as my signature constitutes below.

Telecounselling/teletherapy is a form of psychological service provided via internet technology, which can include consultation, treatment, emails, telephone conversations and/or education using interactive audio, video, or data communications.

I also understand that telecounselling/teletherapy involves the communication of my medical/mental health information, both orally and/or visually. Telecounselling/teletherapy has the same purpose or intention as counselling or psychological treatment sessions that are conducted in person.

However, due to the nature of the technology used, I understand that telecounselling/teletherapy may be experienced somewhat differently than face-to-face treatment sessions.

I understand that I have the following rights with respect to telecounselling/teletherapy:

Client’s Rights, Risks, and Responsibilities:

1. I, the client, have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

2. The HPCSA regulations that protect the confidentiality of information also apply to telecounselling/teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is confidential.

3. However, there are both mandatory and permissive exceptions to confidentiality, which are described in the general Consent Form, I received at the start of my treatment with Mr. S. Khader

4. I understand that there are risks and consequences of participating in telecounselling/teletherapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my counsellor, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. There is also a risk that services could be disrupted or distorted by unforeseen technical problems.

5. In addition, I understand that telecounselling/teletherapy based services and care may not be as complete as face-to-face services.

6. I understand that I may benefit from telecounselling/teletherapy, but that results cannot be guaranteed or assured.

7. I accept that telecounselling/teletherapy does not provide emergency services. If I am experiencing an emergency situation, I understand that I can proceed to the nearest hospital emergency room for help. Clients who are actively at risk of harm to self or others are not suitable for telecounselling/teletherapy services. If this is the case or becomes the case in future, my counsellor will recommend more appropriate services.

8.I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in telecounselling/teletherapy. I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my telecounselling/teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telecounselling/teletherapy session. It is the responsibility of the psychological treatment provider to do the same on their end.