By providing the information below, you confirm that you have obtained consent from the person listed to provide their contact details as your emergency contact for your child in the event that I cannot get hold of either parent/guardian. You also therefore consent that I can contact this person in the event of an emergency and disclose any personal details that I deem appropriate. You also agree to notify me of any changes to this emergency contact information.

*Medical aid rates differ and are plan dependent. It is your responsibility to check for availability of medical aid funds. If payment is rejected by the medical aid then the person responsible for the account is liable for any outstanding fees.

THERAPY INFORMED CONSENT AND AGREEMENT

Online Therapy 

Welcome! This document contains important information about my professional services and practice policies. Please read through this form carefully and make note of any questions or concerns that you might have so that we can discuss them. When you sign this document, it will constitute an agreement between us.

I work exclusively online providing Teletherapy through platforms such as Zoom. Although Zoom is well encrypted, confidentiality on online platforms is not guaranteed. I will ensure that the therapy session takes place in a confidential space with good connectivity and ask that your child does the same. To enable the smooth running of the session, I recommend that the device used rests on a stable surface and shows your child’s face clearly. If connectivity is continuously disrupted during a session, we may have to consider alternative platforms such as a WhatsApp video call. Please note that recording of any session is not permitted.

It is important to note that online therapy is not for everyone – if at any time you or your child decide that working with a therapist in person is preferred, please inform me and I will send you a list of recommended psychologists who are based in your area. Online therapy is not suited to someone in crisis, with self-harm/suicidal risk or in need of risk management (e.g. inpatient admissions). If at any time I feel that online therapy is not clinically adequate for your child, I will need to refer you to a trusted colleague who can see them face to face.

Benefits and Risks

Therapy has both benefits and risks for your child. Therapy can help your child to gain a new understanding about problems and to learn new ways of coping with and solving problems. Therapy can contribute to an improved ability to cope with stress, difficult situations, facilitate resilience and resources of strength, and increase understanding of the self and others. While you can expect benefits from this treatment for your child, no particular outcome can be guaranteed. While there are many methods that I may use to address the concerns your child presents with, psychotherapy requires an active effort on the part of your child and yourself as parents.

Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. This is part of the process of therapy, and we will manage this together. At times it may seem that your child gets worse before they get better. This is part of the process of therapy, and we will manage this together.

As parents you are free to discontinue your child’s therapy at any time but for the benefit of your child, it would be best to discuss any plans to end therapy with me before doing so. Our first few sessions will involve an evaluation of your child’s needs. By the end of these sessions, I will be able to offer you some initial impressions of what our work will include.

Appointments

Online appointments are 50-55 minutes in duration, at a typical frequency of once per week, or as agreed upon. The time booked for your child’s appointment is scheduled to them alone. You or your child are responsible for logging on at the scheduled time. If your child is running late for their appointment, please inform me. Please note that their appointment will still end at the scheduled time and you will be charged for the full appointment time. Should you fail to inform me of late attendance, I will wait for 15 minutes, whereafter I will consider the appointment as a missed session.

Cancellation of Appointments

If you need to cancel or reschedule a session, I ask that you provide me with (at least) 24 hours’ notice. I require this time to contact clients on my waiting list in order to fill the time of the cancelled
appointment. If you miss a session without cancelling, or cancel with less than 24 hours’ notice, my policy is that you will still be responsible for the full payment. Missed or late cancelled appointments will be invoiced as such, and your medical aid (if applicable) will not pay for the missed appointment.

Fees and Non-Payment of Fees

My fees are R1200.00 for a 50–55-minute session. Fees are payable by EFT on the day of your session. Please send me an e-mail or SMS the proof of payment to me. Banking details: ABSA Bank, Stephanie de Raay Psychologist, account number: 4106345689, branch code: 632005.

Please note that I am contracted to a select few medical aids and if arranged, I can submit directly to your medical aid provided that you have the availability of funds subject to your plan. It is your responsibility to check for availability of medical aid funds. If payment is rejected by the medical aid then the person responsible for the account is liable for any outstanding fees.

Should you be paying privately or with a medical aid I am not contracted to, I will e-mail you a statement at the end of your session for direct payment, which can then be sent by you to your medical aid for reimbursement.

Please note that it is my right to employ a debt collector if you do not make payment for the professional services provided by me to you. You will be responsible for additional costs accumulated in the process of debt collection.

Medical Aid

Medical aids will generally only cover a certain number of sessions for the year. It is advisable to contact your medical aid to ascertain how many sessions your medical aid will pay for your child. Some medical aids have extended benefits. This service must be applied for and once approved, the medical aid will continue to reimburse you. By signing this agreement, you agree that I can provide diagnostic and service related information on the invoice to your medical aid. You have the right to not submit my invoices to your medical aid for reimbursement.

ICD 10 Codes
Medical aids require an ICD 10 Code (a medical diagnosis) on your invoice for payment of claims. Please note that I do not have control over the management and use of your child’s ICD 10 information by your medical aid. I will discuss the ICD 10 code I plan to use for these invoices in the first session. It is your responsibility to timeously enquire about anything regarding this ICD 10 code that you wish to know or do not understand.

Prescribed Minimum Benefits
Prescribed Minimum Benefit (PMB) applications (if applicable to your child) are emailed directly to medical aids in PDF format and contain diagnostic and treatment information. I can only apply for a condition that is specified on the official list of PMB’s and if your child meets the criteria for one of these conditions. I can only assess this in our first appointment, unless they already have a PMB authorisation in place from another health professional. PMB benefits are only valid if you do not have any exclusion/waiting periods on your medical aid membership for mental health. PMB benefits include up to 15 outpatient appointments per year (Psychology and Psychiatry included) or 21 days in a psychiatric hospital. If your child has used a few PMB appointments in the year and then requires a hospital admission, the medical aid will work out how many days (of the 21 days) they are able to use for the admission. They use a specific pro-rata formula. It is your responsibility to keep track of the number of sessions used during the year.

Once a PMB is applied for, this ICD 10 diagnosis remains on your child’s medical record. This might have future implications for life insurance policies, emigration - amongst other applications that ask for your child’s medical records. I cannot guarantee that this won’t have any implications.

Contacting Me

I am available from Monday to Friday from 8am-5pm. If I do not answer a call, reply to a text message or e-mail immediately it is likely that I am working with clients. If you leave a detailed message I will get back to you as soon as I am able to. I am unavailable on weekends and public holidays. If you feel you cannot wait for a return call from me or for your next appointment, or if you feel you are unable to keep yourself safe, please go to your nearest Hospital Emergency Room.

Limits of Confidentiality

All information shared with me is confidential and no information will be released without prior consent. During the course of therapy it may be necessary for me to communicate with other health care professionals. Consent to release information is given through written authorisation. There are specific and limited exceptions to this confidentiality which include the following:

A. When there is a risk of imminent danger to your child or to another person, I am ethically bound to take necessary steps to prevent such danger.

B. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, I am legally required to take steps to protect the child, and to inform the proper authorities.

C. When a valid court order is issued requesting medical records, I am bound by law to comply with such requests.

I am under no obligation to write up written reports of any nature relating to any service offered. I do not provide psycho-legal or forensic services as my services are purely therapeutic in nature.

I the mother/guardian of the above mentioned minor, have read and understand the benefits and risks associated with therapy and I also agree that I have the proper legal status to give consent to therapy for the above mentioned minor. I hereby give consent for psychological therapy of my child. I understand that therapy can be stopped at any time.

I the father/guardian of the above mentioned minor, have read and understand the benefits and risks associated with therapy and I also agree that I have the proper legal status to give consent to therapy for the above mentioned minor. I hereby give consent for psychological therapy of my child. I understand that therapy can be stopped at any time.

I look forward to working with your child.