Revelations Quest Psychology

Embrace your journey to self and wellbeing

Individual Psychotherapy Consent Form

This is a consent form for individual psychotherapy. This form needs to be filled in to indicate that you 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.

Client Details:

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Consent Form Submitted!

Hi Valued Client, Thank you for completing and submitting the informed consent form for psychotherapy. We look forward to walking the journey with you.

Names and Surname

Date of Birth (YYYY-MM-DD)

Identity Number/Passport Number

Email Address

Phone Number

I, above-said client, hereby voluntarily consent to:

Receiving psychological services (including screenings, assessments, psychotherapy, etc.).
The discussion of my clinical information by a multi-professional team where need be. All patients’/clients’ rights are protected in terms of the regulations set by the Health Professions Council of South Africa (HPCSA).
Undergo any necessary psychometrics tests and/or treatment advised and explained to me.
Reports being obtained by other authorised and appropriate sources (e.g. school, employer, GP, psychiatrist, court of law, etc.).
A relevant psychological report about me being submitted to institutions as authorised by me.

NOTE: No psycho-legal/medico-legal reports will be written/provided by the treating psychologist. If such services are required, the client is encouraged to seek help from another psychologist in that regard.

I understand that all communication and all records relating to the provision of the psychological services to me are confidential, but there are limitations to confidentiality as explained to me.

I acknowledge that I had the opportunity to carefully read the informed consent form, to ask questions, or communicate concerns arising from it. I further acknowledge that I have and understand the information contained in the form, and that I give my consent willingly on the following date:

Today’s Date (YYYY-MM-DD)

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.

Full Names and Surname

Date of Birth (YYYY-MM-DD)

Identity Number/Passport Number

Relationship to Client (e.g. 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 Plan/Option

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 warm 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 if 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