Payment information:

Purpose of Professional Contact:

As we begin our work together, it may be helpful for me to know some basic information about you, your history and your concerns. Please take a few minutes to answer these questions the best you can. Anything you share will be kept confidential.

Medical History & Diagnoses:

Family History:

Developmental History:

Sensory Profile:

Psychological Profile:

IMPORTANT NOTICES 

1. The contracted fee for a session is R1244.90. The duration of the session is 50 minutes. Payment is due on the day of the consultation. Annual increases apply from 1 January. 
2. For medial aid reimbursement, terms are strictly 30 days and interest will be charged on overdue accounts. 
3. Please pay your account directly and then claim from your Medical Aid, who will reimburse you according to their scale of benefits. It is your responsibility to establish the rates, requirements and limits of your Medical Aid. Medical Aid claims made on your behalf including Prescribed Minimum Benefit (PMB) applications are done so by arrangement only and are billed at the scheme rate. 
4. If you wish to claim from your Medical Aid, an ICD10 diagnostic code(s) will be reflected on your account. 
5. Appointments may be cancelled with at least 48hours notice. if you fail to attend your scheduled appointment or fail to cancel your appointment with 48hours notice this practice reserves the right to charge, as pre-liquidated damages, the full fee for the appointment in the sum of R1244.90. This is irrespective of the reason. The patient or person responsible for payment agrees that such amount is fair and a reasonable reflection of the damages suffered by the practice. Please note that fees due for cancellations/late rescheduling are to be borne by the person responsible for the account, medical aid will not cover these charges. Appointments falling on a Monday require notice of cancellation by Friday at 16h00. Late arrivals will not result in sessions being extended. 
6. it is your responsibility to inform the practice of any changes to the above information.
7. Legal and tracing costs for the collection of unpaid accounts will be borne by the person responsible for the account on an attorney/client scale, including collection fees. Information (name, contact number, address and identity number) will be disclosed for tracing purposes. 
8. Sessions and client information are regarded as strictly confidential.
9. Please be advised of the limits of confidentiality in cases where you may pose a risk to yourself or another person, or where the Psychologist is required to disclose information by a court of law. 
10. You hereby consent to the processing of your personal information as defined in the Protection of Personal Information Act No. 4 of 2013 by Ms. Nicholas, staff and third parties with whom Ms. Nicholas has a contractual relationship for the following purposes: 
    1. Treating and managing you in terms of a Psychologist - Patient relationship
    2. The administration of the contractual relationship between yourself and the Psychologist.
    3. Communicating with other persons in as much as it relates to your treatment and management 
    4. Communicating with third parties who have undertaken to indemnify you for the costs of your treatment and management, or part thereof, including medical schemes and administration where relevant; and 
    5. Collecting monies owing from you 
11. Letters written at your request will be charged at our hourly rate. In all cases this charge includes time spent preparing the letter, collaboration with yourself, amendments, and additional copies being sent to other parties where required. Letters and cost of creation will be discussed with clients prior to sending. Where the client is not the person responsible for the account, it is the client(s) responsibility to obtain authorisation from the person responsible for the account prior to the letter being created. 
12. As a Counselling Psychologist, Ms. Nicholas is trained and experienced in diagnosing and treating a range of disorders of mental health and challenges of adjustment and lifestyle. During the initial consultations with yourself Ms. Nicholas will make an assessment of your presentation and will make recommendations based on this assessment. If Ms. Nicholas believes that you may be more appropriately treated by an alternative professional she will discuss this with you and make these referrals where necessary. 
13. I acknowledge that digital communication is required as part of effective business practice and that there is always a risk of digital information being intercepted or compromised. If you do not wish to receive digital communication please make this known to the therapist at first session (intake). 
14. Please discuss any queries you may have regarding this contract with Ms. Nicholas prior to signing it.