Revelations Quest Psychology

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Couples/Family Psychotherapy Consent Form

This is a consent form for couples and/or family psychotherapy. This form needs to be filled in to indicate that all parties are willingly committing to psychotherapy at Revelations Quest Psychology (RQ Psych). Please complete it and submit it, as psychotherapy cannot commence before it is submitted and received.

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Person Responsible for Account:

By providing the information below, you acknowledge that the individual is aware of such responsibility, and gave you consent to make such information available.

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Thank you for your response. ✨

Full Names and Surname

Date of Birth (YYYY-MM-DD)

Identity/Passport Number

Relationship to Client (i.e. Parent, Sister, Aunt, Partner, etc.).

Occupation

Home Language

Email Address

Phone Number

Medical Aid Details:

By providing this information, you are consenting for the treating psychologist to claim for sessions from your medical aid scheme.

Medical Aid Scheme

Main Member’s Name and Surname (00)

Main Member’s Relationship to Client (i.e. Spouse, Child, Parent, etc.).

Membership Number

Client’s Dependent Number (i.e. 01, 02, 03, etc.).

Home Address

Emergency Contact Details:

In the event of an emergency, such as when one is a danger (physically/emotionally) to themselves or other(s), the clinician is legally obligated to warn the person in danger, and/or in a position to contact a 3rd party to help mitigate danger to self and/or other(s) (e.g. emergency services, trusted individual/next of kin, authorities, etc.).

This is a trusted individual that can be contacted in the event of an emergency. By providing this information below, you acknowledge that the individual is aware of such responsibility, and gave you consent to make such information available.

Full Names and Surname

Date of Birth (YYYY-MM-DD)

Relationship to Client (i.e. Cousin, Partner, Sibling, etc.).

Home Language

Phone Number

Home Address/City