Consent Form - Dr Matete

Section A: Client information

Full Name *

Surname *

Preferred name

Marital Status *

Home language *

Age *

Date of Birth *

ID Number *

Cell No *

Email Address *

Home Address

Home Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Separate Billing AddressYesSelect this option if you have a separate billing address.

Billing Address

Billing Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Contact details in case of emergencies

Name *

Surname *

Relation to client *

Contact No *

Name

Surname

Relation to client

Contact No

General Practitioner

Contact No

Referred by *

Payment options (tick the appropriate one)

Medical AidEFT prior to session

Proof of Payment

Medical aid details:

Medical Aid Name *

Number *

Type of Plan *

Client code *

Are you PMB approved? *YesNo

Upload PMB Approval *

No file chosen

Details of person responsible for account (Leave blank if same as client information)

Title

Surname

Name

ID

Relation to client

Cell No.

Billing Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address

Section B: Informed consent and Professional Agreement

This document contains important information about my professional services and defined rights and responsibilities by you as the client and myself as psychologist in order to make this a mutually beneficial relationship. When you sign this document, it will also represent a legally binding agreement between us. You may revoke this Agreement in writing at any time. I 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) as may be provided by Dr Matete Lerutla, Clinical Psychologist registered with the HPCSA. I understand and agree to the following terms:I 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) as may be provided by Dr Matete Lerutla, Clinical Psychologist registered with the HPCSA. I understand and agree to the following terms:Service and function of psychologist I enter this relationship in full consent with my understanding that the sessions held with the psychologist are meant to help me address issues that require professional help. I realise that psychotherapy often lead to confronting ‘buried’ emotions, which might make me uncomfortable at times. I realise that to achieve the best results, I would need to attend my sessions regularly as arranged. The desired outcomes from psychotherapy are best achieved when I show commitment and do not feel forced to be in therapy. Should at any point feel that I am no longer committed to continuing with the session, I am free to discontinue. I also acknowledge that the psychologist may initiate termination of therapy if, in her assessment, the therapy is not in my best interest. The psychologist might also refer me to see other specialized health professionals should her assessment identify a need for it. Sessions are normally booked weekly or bi-weekly for 55-60 minutes. Longer sessions will be billed according to the prescribed rates.Confidentiality and record keeping: Confidentiality will be maintained on a professional basis and all information collected about me, my work and/or family, will be treated as private and confidential. Should there be a need to discuss my information with other medical professionals to facilitate my holistic wellbeing, I give consent for such information to be released. This will only be with health professionals that I have unequivocally authorised Dr Matete Lerutla to release the information to. Confidentiality can and will be broken in certain situations where maintaining confidentiality would result in clear and imminent danger to myself, the psychologist, or others or as otherwise provided by law. When a threat of bodily harm to others or myself is present, the psychologist may break the confidentiality of communications. I understand that the psychologist will make reasonable efforts to resolve these situations before breaking confidentiality.Record-keeping: Brief records of sessions will be recorded in the form of clinical and/or other notes which will be the responsibility of the psychologist. These records can include interventions used during the sessions and topics discussed. It will be stored electronically and only accessed by the psychologist and her administrative staff. All administrative staff are bound by strict code of ethical and confidentiality conduct. Access of reports is merely to provide administrative support i.e. getting the file ready for sessions.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 spend on writing the report/letter) will be charged.Practice fees and payment: I understand the payment options selected and information described in this contract regarding payment thereof. Cash payment The first consultation fee is payable upfront, not less than 24 hours before the commencement of the session. An invoice will be issued to you should you wish to claim back from your medical aid. Since the fee is already below the fee recommended by most medical aids, no further discount for cash payment will be considered. Subsequent sessions may be paid upfront using EFT or by using Snapscan facilities at the establishment. For Snapscan facility, the payment is due at the end of the session. Medical aid payment Medical aid claims will be processed from the second session onwards. Medical aid patients will be charged at the standard medical aid rate that is supplied by the medical aid. Other costs If my psychologist spends more than 10 minutes a week responding to phone calls or e-mails regarding my care, treatment or management, I will be billed accordingly for this time. General Payment terms: Practice fees and charges remain payable in full by the client or the person responsible for payment of the practice fees and charges. Should the medical aid not pay in full for services rendered, the client remains responsible for the payment of any outstanding amounts. Statements will be issued from DRM IGNITE PTY LTD and will be sent via e-mail at the end of every week. Payment of outstanding amounts need to be made within 7 days after statement date. Failure to pay outstanding amounts within 7 days after the statement date will result in monthly interest of 5% to be added to your account. Failure to pay outstanding accounts within 60 days after this statement date will result in Dr Matete Lerutla contracting the services of a reputable debt collecting agency to collect the outstanding fees and charges. The client will be responsible for all legal fees incurred, including attorney fees and a collections commission of 10% per instalment.Late Arrival, Non-completion, Cancellation, Late Cancellation and Missed Sessions Fees are charged in full for all appointments and services scheduled, including where a person is late for an appointment or does not complete a particular scheduled service. I understand that regular scheduled sessions are part of the commitment and that I should inform the practice at least 36 hours in advance if I am unable to keep an appointment. I understand that I will be held liable to pay a consultation fee should I fail to inform the practice 36 hours in advance. Should I miss an appointment, it is my responsibility to contact the practice and reschedule. Appointments that cannot be held may be rescheduled for another appointment at no extra charge, provided such notice is given to the practice at least 36 hours in advance. Appointment(s) that are NOT rescheduled at least 36 hours in advance or where a client does NOT arrive for an appointment or summarily cancels and reschedule, will be liable for a cancellation fee equal to the applicable practice fee and charges. Cancellations should be communicated by sending a WhatsApp message or direct call @ +27 76 143 9679 or by email: therapy@drmatete.co.za.

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