Esmarilda-Dankaert-Logo

Esmarilda Dankaert

Counselling Psychologist & Wellness Consultant

Mobile | 072 089 3867
Email | info@esmarildadankaert.com
HPCSA No | PS0138100 BHF Practice Number | 0729949
Address | 76 Regent Road, Sea Point, CT, 8005

 

Psychotherapy Intake and Consent Form

 

Patient Information

Medical Aid Information

Parent 1 Information

Parent 2 Information

Guardian Information


Psychotherapy Information and Consent

Please read the following information carefully. It is important that you read it fully prior to consenting to start psychotherapy. Should you still have any queries after reading through this document, please feel free to email me directly at info@esmarildadankaert.com or feel free to send me a message via Whatsapp on 072 089 3867. Given that I am in sessions most of the day, I am not always able to answer my phone, but I promise to get back to you as soon as I am available.

Consultation Protocols

Adolescents

Adolescents aged 14-19 years, are required to give therapeutic consent and are entitled to the same confidentiality as that as an adult. This means that the psychologist may not disclose any therapeutic information to another party if the child has not given his/her consent to do so. As the parent/legal guardian, you acknowledge this confidentiality agreement. Parental consent for therapy is not legally required.

For adolescents aged 10-13 years, consent from both parents is required, except in cases where one parent can prove that he/she has full legal custody of the child. For the adolescent to attend therapy, both parents need to sign the consent form. Therapy cannot commence until consent from both parents has been received.

In-Person Psychotherapy

In-person sessions take place at my practice in The Point Shopping Centre, 76 Regent Road, Sea Point. The practice is situated on the 3rd floor (suite 307), within the Atlantic Chiropractic Centre. 

Online Psychotherapy

Online consultations will take place only via Zoom, as the Zoom platform has shown to be the most secure and effective alternative to traditional face-to-face consultations. However, online consultations always carry their own limitations such as possible technological difficulties, disruptions, loss of connection, and/or potential power failures. As such, should our online session get disrupted in any way, I will try my best to re-establish a connection as soon as possible. If the Zoom call is repeatedly unsuccessful for 10 minutes, one of the following protocols will be followed:

  • During the first 10 minutes of our session: I will phone you to reschedule for another time, and no fee will be charged for the session.
  • During the first 20-30 minutes of our session: I will phone you to reschedule for another time, and a 30-minute fee will be charged for the session.
  • During the last few minutes of the session: I will phone you to summarise and consolidate the session and we will terminate the session telephonically.

For us to engage in online consultations, you will require a device that can connect to the internet and be able to download and install the Zoom software. A reliable highspeed internet connection is also required to ensure that our session takes place without any voice or video delays.

Fees and Payment

Sessions are 45-50minutes in length and billed at R1180 per session, which is in line with standard medical aid rates. Payments are made right after each session at reception, using either a debit or credit card. For those who prefer to make an EFT prior to their session, you are welcome to use the following banking details:

Name: Esmarilda Dankaert
Bank: ABSA
Account no: 4065046061
Type: Cheque account
Branch: 632005

Prescribed Minimum Benefits (PMB)

Psychotherapy is often covered by the medical aid through what is known as prescribed minimum benefits or PMB. I can apply for PMB approval for patients on their request. However, patients remain responsible for settling their account directly with me and submitting their paid invoice to their medical aid for reimbursement.

Patients are also reminded that they remain responsible for the payment of their sessions until PMB approval is received. Please note, PMB applications submitted do not guarantee their approval. Therefore, it remains the responsibility of patients to settle their account in full.

If PMB benefits are approved, you remain responsible for tracking how many approved sessions you have remaining. Should you run out of approved sessions, any additional sessions fees will remain to be settled by you privately.

Appointments and Cancellation Policy

If, for whatever reason, you are running late, kindly let myself or the practice (021 439 8898) know. Should you need to reschedule or cancel an appointment, please notify me 24 hours prior to our appointment. In case of emergencies, accommodations will be made. Should you fail to notify me and miss a scheduled appointment, you will still be billed for a full session.

Psychological Assessments

Psychotherapy can often entail the use of psychological assessment measures to help with personal growth and development, or aid as diagnostic tools. All of the psychological assessments I use have shown to be scientifically valid and reliable and are approved by the Health Professions Council of South Africa (HPCSA). Additionally, all information obtained from these measures will only be used for purposes of assisting with personal development and/or career guidance and will by no means be used for psychological or forensic purposes.

Confidentiality

In keeping with ethical standards as set by the Health Professions Council of South Africa (HPCSA), as well as global relevant legislation, all information shared as part of our consultations and from any assessment measures, are kept strictly confidential. No information will be released without your prior consent.

Limits of Confidentiality

In the case of online consultation, the internet is used for the transmission of personal information. Consequently, this poses a potential risk to confidentiality, and therefore, complete confidentiality cannot be guaranteed. To ensure confidentiality as far as possible, we make use of Zoom, which is software that provides encryption to communicate. During online consultations, please ensure that you use a private environment so as to protect your own and my confidentiality. Additionally, all patient information captured is stored securely on a password protected database.

In the case of in-person consultations, there are a handful of situations in which the normal rules regarding confidentiality do not apply. In keeping with ethical standards as set by the Health Professions Council of South Africa (HPCSA), as well as relevant legislation, all information shared within psychotherapy is kept strictly confidential and no information will be released without the consent of the minor. However, there are limits to this confidentiality agreement, and these include the following:

  • When there is risk of imminent danger to the therapist or to another person, the therapist is ethically bound to take necessary steps to prevent such danger.
  • When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the therapist is legally required to take steps to protect the child, and to inform the proper authorities.
  • When a valid court order is issued for medical records.

POPI Act

As the practicing psychologist, I collect, treat and store all patients’ personal information for the purposes of providing therapeutic services and for billing purposes. All information is processed in a reasonable and relevant manner, as well as treated with confidentiality and in line with the POPI Act.

For invoicing purposes, patients are informed that I will have to share specific personal information for reimbursement purposes. However, these will be limited to only information that is required for reimbursement to be successful, such as name and surname, contact details, ID number, ICD-10 code, and membership details.

Patients are reminded that, for claiming purposes, I will need to submit an ICD-10 code on your invoice in order for you to claim from your medical aid. This ICD-10 code gives an indication of the condition that you are being treated for. As the patient, you have the full right to know what this code means and can discuss this with me.

By submitting invoices to your medical aid, please note that other members/beneficiaries on your medical aid may have access to information pertaining to your claim. Therefore, once you submit an invoice to your medical aid, the release of that information is your responsibility. As your psychologist, I am unable to protect your personal information in that capacity.

In order to keep your information up to date please continuously provide me with your latest contact detail and ask for deletion of any information if you no longer want it to be stored by the practice. Should you as the patient wish to request specific information held by the practice, you can complete and submit an application form as per the PAIA policy. The practice reserves the right to approve or deny applications.

All attempts have been made to ensure that procedures and systems used to run my practice and provide effective psychotherapy services are POPI compliant.

Informed Consent

By digitally signing below, I as the client/parent/guardian, hereby confirm that I have read and fully understood all the information provided to you in this Psychotherapy Intake Form. Further, I accept, understand, and agree with the information and terms of this agreement. I further acknowledge that by submitting this document, it serves as my “YES” and informed consent.

Sign Here