1.1 Accounts are deemed to have been received five (5) days after dispatch and to be correct in all respects unless I notify the Counsellor 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 21h00 on weekdays, as well as all 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 therapy 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 amounts 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 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 contactdetails.
1.8 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.
1.9 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 theCounsellor.
2.1 While fully understanding that the Counsellor will try his best to help me resolve my problem or symptoms, I fully understand that there is no guarantee that thetreatment will be successful.
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- orvideotapes 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 Hypnosis.
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 myactions.
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, fir e, 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.
I agree to be punctual for scheduled appointments. Please understand that I am on call at the Hospital, and at times, may have to leave re-schedule within a very short period of notice. If this does occur, I will setup another appropriate time and date for your appointment. Thank You for understanding.
4.1 All appointments must be cancelled at least twenty-four (24) hours before the scheduled time otherwise a full appointment will be 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 twenty-four (24) 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 (24) 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.
Thank you for your understanding and co-operation. The undersigned declares that he/she is familiar with the terms of this practice and that it is accepted as such.