ImpressumIn this consent contract, ‘I’ refers to Dr Safia Mohamed, BSocSci (Psych), BEd Hons (Psych), MEd (Ed Psych) PhD (Ed Psych) (Pretoria) Dip. (VUE Life Coaching), [*PS No.: 011 5290 *PR No.: 042 7535].
Evaluation phase
In order for me to render a service to you (and/or your child), I need to do a proper evaluation to gain understanding of your context and experiences. In the course of this evaluation I will ask you a number of pertinent questions about yourself, your family (and/or your child). It is possible that I may need to do psychological testing and for that we will need additional sessions. It is also sometimes valuable to interview other people (family members, teachers or other professionals) who know you (and/or your child) to obtain additional information. I will only do so with your consent. After the evaluation we will have a session where we will discuss my findings and decide on a future plan of action. This evaluation and report-back phase normally takes 2-3 sessions and should I require more time I will discuss this with you.
Therapeutic phase
Therapy usually brings improved functioning and personal growth in the long term. In the short term, however, it may be an unsettling experience, as it is usually an emotional experience. Some temporary emotional distress is possible. This may have a negative influence on you. In the case of child clients, their schoolwork as well as social and personal functioning for a period of time may be influenced.
The purpose of therapy is to bring about change. This may specifically induce you (or your child) to bring about changes in your relationships with others. Such changes are often not welcomed by those affected and this may lead to interpersonal tension. The success of therapy is influenced by a number of factors. One of the most important factors is the degree to which the patients take responsibility to bring about change. No therapist can give a guarantee that therapy will be successful. The therapeutic process is intended to help you overcome the presenting problems/difficulties sufficiently, to enable the patient to develop greater purpose and autonomy in their life without the support of continued therapy/counselling, as far as reasonably possible.
Telepsychology
This Practice makes use of telepsychology extensively. Telepsychology refers to remote consultation with patients using telephonic or virtual platforms for consultation. Within the digital world, all engagement with patients and data resulting therefrom will be protected to respect the privacy and confidentiality rights of a patient (and/or their family).
Telepsychology requires the establishment of the therapist-patient relationship. Where there is doubt whether a telehealth consultation will be in the best interest of a patient, the patient will be encouraged to present themselves for a face-to-face consultation or to seek assistance from a practitioner at a health care facility closest to them.
Media Activities
A substantial part of my working life outside this practice exists within the public domain where I fulfil multiple roles. As such, I maintain an active social media presence to enable me to reach a broader community with whom I can share psychological concepts that I hope can be useful in their daily lives and development. In order to maintain interpersonal boundaries for the wellbeing of my patients, I keep my clinical practice and my online social media separate and therefore will limit personal online engagement with my patients.
Confidentiality
∙ I will treat all the private information I collect about you/your child/your family as highly confidential. I will not, subject to what is stated below, disclose any information about you without your consent. ∙ In certain exceptional situations, however, legal or professional rules may force me to disclose information about you. This will include:
∙ Emergency situations: In this regard I want you to know that should a situation develop where I believe that there is a real risk that your child may harm him/herself, another person, or myself, I will be compelled to take the necessary steps to prevent such harm, even if this may entail my breaching my promise to you to keep information confidential.
∙ Statutory duty: A provision in an Act may oblige me to disclose confidential information about you/your child/your family.
∙ Court orders: A court may order me to disclose private information. In terms of my professional rules I must, however, endeavour to do everything possible to prevent the disclosure of your private information.
∙ That which I have pointed out above is also applicable in respect of children under the age of 18. I will on a regular basis inform parents or guardians about the therapeutic process and the progress of the patient. As a general rule, no information will be given to a parent or guardian about the content of a session without the relevant patient’s (/child’s) consent. I do, however, reserve the right to inform a parent or guardian if it appears that the relevant child makes him or her guilty of criminal behaviour, or threatens with, or is involved in behaviour that I consider being dangerous or potentially dangerous.
∙ Subject to what is stated about confidentiality, I will not issue a report regarding your child without your consent.
Fees
∙ Psychology tariffs within the Republic of South Africa (RSA) vary according to different medical schemes. ∙ The cash rate of this practice is subject to change without prior notification. Consultation fees are payable at the end of each individual consultation (unless otherwise agreed upon).
∙ Cash payment can be made via EFT bank payment or PayPal invoicing. Please enquire regarding the updated rate at the time of booking an appointment.
∙ Normal practice rates will apply for telepsychology services rendered through any telehealth platform through this practice.
∙ Telephone calls lasting longer than 10 minutes will be billed to the patients account or medical aid fund respectively.
Informed consent
I also bind myself by contract with regard to the following:
∙ I, therefore hereby grant permission to the Psychologist of this practice to obtain information from or provide it to authorised persons and parties as agreed upon, if this is regarded to be in the interest of my child, my family or myself. ∙ Written reports - apart from feedback – are provided on request only, and at an additional fixed rate (enquire regarding current rate which may be subject to change without prior notice).
∙ I realise that, although the Psychologist will provide certain recommendations, the sole and final responsibility for decision making remains my own and the Psychologist of this practice may not be held responsible for my choices. I realise that analysis of the options is of crucial importance when making my final decisions.
∙ In the case of career counselling, the chances of making choices that are based on insufficient information are greatly enhanced if I do not carry out a proper job analysis beforehand. The Psychologist of this practice may therefore not be held responsible for my career choices.
∙ If I choose to use my medical aid to cover the psychological services offered by this practice, my signature on this document serves as consent to allow (relevant) information to be provided to my medical aid fund in order to process my claims.
∙ I undertake to settle the account in cash or by cheque after each psychotherapeutic and psycho-diagnostic session regardless of the platform used to conduct the session (applicable to patients not claiming from medical aid schemes). ∙ If any fees are outstanding after 30 days and arrangement for payment has not been agreed upon, then legal action may be taken against me for the settlement of the account, all the ensuring costs will be my responsibility. ∙ I further agree that a full consultation fee (60 minutes) may be charged to my account (or claimed from my medical aid) for appointments not cancelled at least 24 hours in advance.
∙ The focus of this practice is therapeutic. The psychologist of this practice does not undertake expert witness work or agree to provide legal evidence of any kind, be it with regards to custody and divorce issues or any other matters. Assessment reports that may be issued are intended to assist individual, parents, teachers and caregivers, and to identify appropriate treatment, rather than for use in legal matters.
∙ All therapeutic work conducted in this practice is aimed at aiding the development (and/or learning processes) of the patient. The Psychologist of this practice may refer appropriately, as deemed necessary.
∙ I understand there may be potential risks to using telepsychology methods, including interruptions, unauthorised access risks and technical difficulties. I also agree not to record any sessions or part thereof.
∙ Responsibility to have adequate technology and privacy in place to receive telepsychology services lies with the patient, which I hereby consent to.
Disclaimer
By signing this document I (the undersigned) indicate that I have reviewed, understand and agree to comply with the policies/statements in this agreement and that I consent to psychotherapy/counselling for myself/my child/my family. I accept responsibility of all the above and will not at any time hold Dr Safia Mohamed liable for any costs (including legal proceedings).
