Child Information and Consent Form.
I, the undersigned, grant Naomi Holdt permission to treat myself or legal guard in her capacity as a psychologist. I hereby give permission to the therapist to interview, assess and treat me according to the guidelines and terms mentioned below
I, the undersigned, understand and acknowledge the following.
All information will be treated as confidential. There are times where a legal or ethical obligation rests on the therapist to disclose information. It is required by law to report to the appropriate authorities any suspected, past or present, child abuse, elder abuse or abuse of people with disabilities. When a threat of bodily harm to self or others is present, the therapist will break the confidentiality of communications. This includes receiving a court order for disclosure.
With consent, relevant information may be discussed with the referring psychiatrist or other mental health professionals registered with the Health Professions Council or South African Social Work Council.
Consultations are payable in cash (in an envelope, marked with your name) on the day of the session or by eft in advance and proof of payment brought to the session or notification sent prior to the session. NO sessions, without exception, will be conducted if payment has not been made prior or at to the appointment time.
Account details as follows:
Acc No: 060896752
Branch number: 057525
I, the undersigned, accept full responsibility for my account and to settle any outstanding payments. Moreover, I accept full responsibility to ensure that I have received the necessary invoices for sessions that I have attended.
I understand that Naomi Holdt may suspend therapy until all outstanding accounts are settled in full
Should you not be able to keep an appointment you must please cancel it. If you fail to do so more than 24 hours in advance, the person liable for payment of the account will be held liable for payment of the full amount for the missed session. Please be aware that Medical Aid Schemes will not pay for missed sessions and should you be a medical aid patient, you will be liable to pay for these.
Telephone consults will be charged for at the average recommended medical aid rate for consultations. This equates to R150.00 per five minutes or part thereof.
Email consultations will be charged for at the average recommended medical aid rate for consultations. This equates to R150.00 per five minutes or part thereof. Consultation time begins on commencement of your email being read, and ends on completion of my response email.
You may find it more beneficial to book a consultation with me, rather than have a telephone or email consultation.
My working hours are 8:30am until 4:30pm, Monday to Friday. You are welcome to contact me during that time should you need to. It is requested that you be considerate in keeping to these times when you send text messages too. Should I not be available during those times, please leave a message and I will return your call within 24 hours. I will not under any circumstances be attending to any work related matters after hours.
I understand that that the email address and mobile number provided by me below will be used for all correspondence related to my appointments and invoices. Should I not receive the related invoice within 5 working days after a session (those that are attended or missed), I will be responsible for ensuring that I follow-up and ensure that I do have a copy of the related invoice.
I, the undersigned, accept that any late-coming will shorten the length of my session and I will be charged in full. Sessions cannot run overtime if the client is late.
Note that the information below with a ‘*’ is mandatory. If you don’t have this information, you can enter a ‘-‘. However, if the information is missing or inaccurate, it will result in a delay of the appointment scheduling, billing process and/ or medical aid follow-up process.