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Thank you for your response. ✨
Client Name and Surname
(required)
Date of Birth
(required)
YYYY-MM-DD
Identity Number
(required)
Phone Number
(required)
Email Address
(required)
Psychotherapy Format
(required)
Select One Option
Couples Therapy
Family Therapy
Other Individual(s) To Be Present for Therapy
(i.e. Names & Surnames, Date of Birth, etc.) (required)
Medical Aid Details:
Medical Aid Scheme
(if applicable, if not state (“N/A” through out) (required)
Membership Plan/Option
(required)
Membership Number
(required)
Dependent Number
(i.e. 01,02,03,etc.) (required)
Main Member’s Details
(i.e. Name & Surname, ID Number, etc.) (required)
Address
(required)
By clicking submit below, you are agreeing to the terms outlined here: No Secrets” Policy – I/We understand that when treating a couple or family, the therapist considers the relationship/family unit as the client. Therefore, any information shared individually with the therapist may be shared with the other partner/family members if deemed clinically necessary for the progress of therapy. Limits of Confidentiality – I/We understand that communications are confidential, except where disclosure is required by law (e.g., danger to self/others, child/elder abuse, or court order). Cancellation Policy – I/We agree to provide at least 24 hours notice for cancellations, or be subject to the standard session fee. NOTE: No psycho-legal/medico-legeal reports will be written/provided by the treating psychologist. If such services are required, the client/patient is encouraged to seek professional help from another psychologist in that regard.
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