STUDENT AND YOUNG ADULT THERAPY

INTAKE & CONSENT FORM

STUDENT EN JONG VOLWASSENE

INNAME- EN TOESTEMMINGSVORM

Practice Information / Praktykinligting

Practice: Psychologist on Herold

Practitioner: Ms Lelani Cloete – Educational Psychologist (HPCSA)

Purpose of this form / Doel van hierdie vorm

• This form helps us understand your child’s needs and obtain legal consent for psychological therapy. / Hierdie vorm help ons om u kind se behoeftes te verstaan en wetlike toestemming vir sielkundige terapie te verkry.

  
  

• This consent remains valid until therapy ends and may be withdrawn at any time in writing./ Hierdie toestemming bly geldig totdat terapie beëindig word en kan enige tyd skriftelik teruggetrek word.

About the service/Oor die diens

Psychological therapy supports individuals with emotional, behavioural, social and developmental challenges. / Sielkundige terapie ondersteun individue met emosionele, gedrags-, sosiale en ontwikkelingsuitdagings.

FEES/FOOIE

Where services are submitted to a medical aid scheme, this practice applies the relevant medical aid tariff rates in accordance with the applicable procedure codes.

For therapy sessions that are privately funded (not claimed from a medical aid), a subsidised private rate of R950 per session applies.

This fee is applicable to:

Procedure code: 86205 – Individual psychotherapy (51–60 minutes).

Fees are payable in accordance with the practice’s billing and payment policy.

Waar dienste by ’n mediese fonds ingedien word, pas hierdie praktyk die toepaslike mediese fondstariewe toe in ooreenstemming met die relevante prosedurekodes.

Vir terapie wat privaat befonds word (nie deur ’n mediese fonds geëis nie), geld ’n gesubsidieerde privaat tarief van R950 per sessie.

Hierdie fooi is van toepassing op:

Prosedurekode: 86205 – Individuele psigoterapie (51–60 minute).

Fooie is betaalbaar ingevolge die praktyk se fakturerings- en betalingsbeleid.

Child’s details/ Kind se besonderhede

Parent / Legal Guardian / Person completing this form

Ouer of Wettige Voog / Persoon wat hierdie vorm voltooi

Address/ Adres

Second parent / guardian (if applicable)

Legal consent for minors/ Regstoestemming vir minderjariges

In terms of the Children’s Act 38 of 2005 (section 129) and HPCSA ethical guidelines, a child from the age of 12 years, who has sufficient maturity and mental capacity to understand the nature and implications of the treatment, may legally provide consent to psychological therapy without parental consent.

Although this is legally permissible, it is regarded as best clinical and ethical practice for both parents or legal guardians to provide informed consent for a minor’s therapeutic process wherever possible, unless a court order states otherwise.

South African law further recognises that, where parental consent is required or relied upon, consent from both legal parents or guardians is applicable, unless a court order provides differently.

Kragtens die Kinderwet 38 van 2005 (artikel 129) en HPCSA-etiese riglyne, mag ’n kind vanaf 12-jarige ouderdom, mits hy/sy oor voldoende volwassenheid en verstandelike vermoë beskik om die aard en gevolge van die behandeling te verstaan, regsbevoeg toestemming tot sielkundige terapie gee sonder ouerlike toestemming.

Alhoewel dit wetlik toelaatbaar is, word dit as beste kliniese en etiese praktyk beskou dat beide ouers of regsvoogde, waar moontlik, ingeligte toestemming verleen vir ’n minderjarige se terapeutiese proses, tensy ’n hofbevel anders bepaal.

Die Suid-Afrikaanse reg erken verder dat, waar ouerlike toestemming vereis of gebruik word, toestemming van beide regsouers of voogde van toepassing is, tensy ’n hofbevel anders bepaal.

CONSENT FROM SEPARATED PARENTS.

In order to authorise mental health treatment for your child (under the age of 18 years), you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorise treatment for your child. If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child. I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment. 

It is also my policy that the parent who initiates therapy shall be responsible for payment of the child's consultations. Discussions around splitting accounts should be held between parents. Furthermore, in the case of separated or divorced parents, the following NON-NEGOTIABLE terms and conditions apply to payments of parent consultations:

• If parents consult with me together, one parent will be responsible for settling the account, as split billing is seen as unethical practice. Discussions around splitting the account should be held between parents before consultations. 

• If parents choose to consult with me separately, each parent shall be responsible for settling their own account. 

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements, or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, parents decide whether therapy will continue. If either parent decides that therapy should end, I will honour that decision, unless there are extraordinary circumstances. However, in most cases, I will ask that you allow me the option of having a closing session with your child to appropriately end the treatment relationship.

Reason for seeking therapy/Rede vir terapie

Current professional involvement / Huidige professionele betrokkenheid

Billing and Medical Aid Information / Rekeningkunde en Mediese Fonds Inligting

Medical aid information (if applicable) / Mediese fonds besonderhede (indien van toepassing)

MEDICAL AID SUBMISSIONS

This practice is able to submit claims to medical aid schemes on behalf of clients, where applicable and where the required information has been provided in full.

Clients remain solely responsible for ensuring that sufficient medical aid benefits, savings, or Prescribed Minimum Benefits (PMBs) are available at the time services are rendered. Medical aid schemes determine benefit availability, authorisation, and reimbursement, and this practice cannot guarantee payment by any scheme.

Clients are further advised that if a medical aid scheme declines, partially pays, or fails to reimburse any portion of an account for any reason, the client (or parent/guardian in the case of a minor) remains fully liable for the outstanding balance.

Clients are therefore required to familiarise themselves with their own medical aid benefits and limits and to ensure that adequate funds are available to cover sessions attended.

Clients also remain responsible for confirming with their own medical aid scheme whether services rendered by an educational psychologist are eligible for reimbursement, as this varies between schemes and benefit options.

At present, the following medical aid schemes are known not to reimburse services provided by educational psychologists:

• GEMS*

• Profmed

• Polmed

• KeyHealth

• Bestmed

• Medihelp

  
  

* GEMS currently reimburses a maximum of two sessions only, and only in the case of school-aged learners or registered students. Thereafter, proof of enrolment or continued studies may be required, and further reimbursement is not guaranteed.

It should be noted that these reimbursement exclusions and limitations are currently the subject of a legal challenge within the healthcare sector, aimed at reviewing the classification and funding of services rendered by educational psychologists. While the outcome of this process cannot be predicted, it is hoped that these policies may be revised in future.

From a professional and public-interest perspective, the restriction or exclusion of educational psychology services from medical aid benefits is a matter of concern, as it significantly limits access to specialised psychological support for individuals, and constrains the recognised scope of practice of educational psychologists within multidisciplinary mental-health care.

If you are a member of one of the above schemes, you may elect to proceed on a private-pay basis, or request referral to a psychologist registered in another professional category who may be able to submit claims to your medical aid.

MEDIESE FONDS EISE

Hierdie praktyk kan, waar van toepassing en mits alle vereiste inligting volledig verskaf is, eise namens kliënte by mediese fondse indien.

Kliënte bly uitsluitlik verantwoordelik om te verseker dat voldoende mediese fondsvoordele, spaargeld of Voorgeskrewe Minimum Voordele (PMB’s) beskikbaar is op die tydstip wanneer dienste gelewer word. Mediese fondse bepaal self voordeelbeskikbaarheid, magtiging en terugbetaling, en hierdie praktyk kan nie betaling deur enige fonds waarborg nie.

Kliënte word verder daarop gewys dat indien ’n mediese fonds ’n rekening weier, slegs gedeeltelik betaal, of om enige rede nie vergoed nie, die kliënt (of ouer/voog in die geval van ’n minderjarige) ten volle aanspreeklik bly vir die uitstaande bedrag.

Kliënte is gevolglik verplig om hul eie fondsvoordele en beperkings te ken en te verseker dat voldoende fondse beskikbaar is om sessies te dek.

Kliënte bly ook self verantwoordelik om by hul mediese fonds te bevestig of dienste gelewer deur ’n opvoedkundige sielkundige vir terugbetaling kwalifiseer, aangesien dit tussen fondse en plan-opsies verskil.

Die volgende mediese fondse is tans bekend daarvoor dat hulle nie dienste deur opvoedkundige sielkundiges vergoed nie:

• GEMS*

• Profmed

• Polmed

• KeyHealth

• Bestmed

• Medihelp

  
  

* GEMS vergoed tans slegs ’n maksimum van twee sessies, en slegs in die geval van skoolgaande leerders of geregistreerde studente. Daarna mag bewys van inskrywing of voortgesette studie vereis word, en verdere vergoeding word nie gewaarborg nie.

Daar word verder kennis geneem dat hierdie uitsluitings en beperkings tans die onderwerp is van ’n regsgeding binne die gesondheidsorgsektor, wat gemik is op die herevaluering van die klassifikasie en befondsing van dienste gelewer deur opvoedkundige sielkundiges. Alhoewel die uitkoms van hierdie proses nie voorspel kan word nie, word gehoop dat hierdie beleide in die toekoms hersien mag word.

Uit ’n professionele en openbare-belang-oogpunt is die beperking of uitsluiting van opvoedkundige sielkundedienste uit mediese fondsvoordele kommerwekkend, aangesien dit toegang tot gespesialiseerde sielkundige ondersteuning vir individue wesenlik beperk, en die erkende omvang van praktyk van opvoedkundige sielkundiges binne multidissiplinêre geestesgesondheidsorg inperk.

Indien u ’n lid van een van bogenoemde fondse is, kan u kies om dienste op ’n privaatbetalingsbasis te ontvang, of versoek dat u na ’n sielkundige in ’n ander professionele kategorie verwys word wat moontlik eise by die fonds kan indien.

Prescribed Minimum Benefits

PRESCRIBED MINIMUM BENEFITS.

In order for us to set realistic treatment goals and priorities for your child, it is important to evaluate what resources you have available to pay for treatment. If you have a medical aid policy, it will usually provide some coverage for mental health treatment, usually making use of your medical aid savings. I will fill out forms and provide you with whatever assistance I can in helping your child receive the benefits to which he/she are entitled; however, you (not your medical aid company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your medical aid policy covers.

You should carefully read the section in your medical aid coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your medical aid company. Due to the rising costs of health care, medical aid benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available.

Prescribed Minimum Benefits (PMB) plans often require authorisation before they provide reimbursement for mental health services. Please note, if you make use of a PMB, you are swapping inpatient care for outpatient therapy. Thus, you may forfeit in-hospital care for your child if you utilise PMB services for outpatient sessions. PMBs are only available for certain ICD-10 diagnostic codes. It is also very important to note that having an approved PMB condition is seen as a pre-existing mental health condition which might cause certain limitations in your child’s future in terms of applying for life cover or moving abroad. You will have to weigh up the pro’s and cons of utilising PMB sessions versus the potential future limitations for your child. 

It is important to note that a child’s mood or emotional functioning may at times be significantly affected by situational or contextual factors (for example, family stressors, school-related difficulties, trauma, or major life changes). In some cases, such circumstances may give rise to a clinically diagnosable depressive episode that meets the diagnostic criteria for a PMB-qualifying condition.

However, I cannot apply for Prescribed Minimum Benefits (PMBs) unless your child objectively meets the formal diagnostic criteria for a PMB condition, as submitting an application in the absence of such criteria would be unlawful, fraudulent, and unethical.

You should also be aware that most medical aid companies require that I provide them with your child’s clinical diagnosis in order to apply for PMBs. Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the medical aid company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit, if you request it. You understand that, by using your medical aid, you authorise me to release such information to your medical aid company. I will try to keep that information limited to the minimum necessary.

Once we have all of the information about your medical aid coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to decide whether or not to submit your statement to your medical aid to avoid the limitations described above.

Patient/client information

Main member details / Hooflid besonderhede

• CONFIDENTIALITY.

  I highly respect the privacy and confidentiality of each of my clients. I likewise believe that for therapy to be effective and successful, I must make my clients feel secure about the information that they disclose to me. I keep my clients' records in a secure manner and I do not allow it to be accessed or to be shared with anyone else unless with the written consent of my client who owns the information, both clinical information and personal. If records receive no update within a period of 7 years, I purge the records for privacy protection.

  However, privacy has its limitations and in some situations, I am required by law or by the guidelines of my profession to disclose information to a third party, whether or not I have your or your child’s permission. I have listed some of these situations below. Confidentiality cannot be maintained when:

  • Child clients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.

  • Child clients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm [and the police].

  • Child clients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.

  • Child clients tell me, or I otherwise learn that, it appears that a child is being neglected or abused --physically, sexually or emotionally-- or that it appears that they have been neglected or abused in the past. In this situation, I am required by law to report the alleged abuse to the appropriate state child-protective agency.

  • I am ordered by a court to disclose information.

    
    

• DISCLOSURE OF MINOR'S TREATMENT INFORMATION TO PARENTS.

  Therapy is most effective when a trusting relationship exists between the psychologist and the client. Privacy is especially important in earning and keeping that trust. As a result, it is important for children to have a “zone of privacy” where they feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement. This includes activities and behaviour that you would not approve of — or might be upset by — but that do not put your child at risk of serious and immediate harm. However, if your child’s risk-taking behaviour becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm. If I feel that your child is in such danger, I will communicate this information to you.

  If your child tells me, or if I believe based on things I learn about your child, that your child is addicted to drugs or alcohol, I will not keep that information confidential. Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life. In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so. Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.

  
  

• LITIGATION.

  When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.

  Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s). 

  Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at my current consultation rate per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.

  
  

• POPIA CONSENT.

  I have implemented a number of procedures in order to protect all personal information of clients / patients in accordance with the Protection of Personal Information Act 4 of 2013. The following POPIA clauses therefore apply in  addition to the contract signed before the first consultation: 

  By signing this consent form, you agree to the following additional terms and conditions: 

  1. By providing the information on your file you consent to this information being kept and  processed for the purposes of providing treatment and for this information to be used to  contact you when necessary. You also agree to notify the practice of any changes / updates to the information provided on your file.

  2. By providing the information of an Emergency Contact, you confirm that you have obtained consent from the person listed to provide their contact details as the person who will be contacted in the case of an emergency. You also agree to notify the practice of any changes to this emergency contact information.

  3. By providing the information of the Person Responsible for the Account you confirm that you have obtained consent from the person listed to provide their contact details as the person who will be responsible for payment of the account. You also agree to notify the practice of any changes to this emergency contact information.

  4. Personal information used for billing may be disclosed to service providers who are involved in or enable the delivery of such services to you, such as medial  schemes or other healthcare professionals, where this is in service of your treatment and where such third parties comply with the privacy requirements as regulated by POPIA. This may include processing and sharing of information for the purposes of collecting unpaid debts. All third parties, with the exception of medical aids who are governed by their own  PAIA manual, have signed a POPIA compliance agreement with the practice to protect the personal information they receive.

  5. Where specific requests are received to disclose information contained in your records (e.g.  medical aid audits), a separate consent to disclose from detailing the particulars of this request will be provided to you.

  6. The practice has installed threat detection software onto all devices containing personal information and the practice will review security  safeguards on an ongoing basis to ensure that your information is kept safe and confidential.

  7. Hardcopy files are stored away in a locked cupboard at all times and all computers and phones are password protected. Despite all these measures, the undersigned acknowledges that there remains a risk of breech of their personal information and does not hold the practice liable in case of such a breech of personal information.

  8. In the case of a breach of personal information, the practice will notify the  individual whom’s information has been breeched as well as notify the Regulator of such breech.

  9. Client / patient records are kept for a period of 6 years from the date of the last consultation or as regulated by professional standards set out by the HPCSA, and will be safely disposed of / destroyed thereafter.

  10. The cellular phone belonging to the practice is not a confidential line and messages will be read by the practice admin team, unless specified as confidential. Whilst all measures are taken to ensure the protection of personal information on electronic devices used by the practice, there is always a risk of personal information breech that may be  unavoidable when using electronic devices, particularly social media platforms such as  Whatsapp.

  11. Information regarding the therapy process will be recorded in order to provide psychotherapeutic services, as per HPCSA regulations and the Protection of Personal  Information Act No. 4 of 2013. This information will only be used for the purposes for which it was collected (providing psychotherapeutic services).

  12. The undersigned acknowledges that using their name as a payment reference will reflect on  practice bank statements and payment notification emails / SMSes. Clients / patients are  therefore encouraged to use invoice reference numbers when making payments.

  13. The undersigned acknowledges that they are aware of their right to request a copy of the practice's POPI Policy Procedures (PAIA Manual), and can find such manual by requesting it from the practice's Information Officer or from the practice’s website.

  14. The undersigned acknowledges that they are aware that they have a right to object to the practice processing their personal information and that they may fill in Form 1 to make this objection known. Form 1 may be requested from the Information Officer at the practice.

  15. The undersigned acknowledges that they have the right to request an update, correction or deletion of their personal information using Form 2 which may be requested from the practice's Information Officer. 

Parental Consent and Acknowledgement/Ouerlike Toestemming en Erkenning