Client Intake Form

1. CLIENT DETAILS

How would you like to be consulted?*
Select oneOnline (remote)In-personResidential (in patient)Employee Assistance ProgramPresentationSeminar

Which kind of support are you seeking?*
Select oneIndividual TherapyCouple TherapyFamily TherapyChild-play therapyAddiction therapyKinesiology TherapyGroup/staff TrainingConference

Which time slot do you choose?*
Select one50-minute session90-minute session110-minute session5 Days10 Days14 Days21 Days28 Days

Your availability/required days?*
Select all that applyMondayTuesdayWednesdayThursdayFridaySaturday

Your availability/required time?*

Please describe your requirements here

Are you the primary person responsible for payment?
YESNO

2. CONTACT PERSON

3. PERSON RESPONSIBLE FOR PAYMENT

4. METHOD OF PAYMENT*
EFTCash

5. REFERRAL

How did you hear about us?*
InternetMedical DoctorPsychiatristPsychologistFriendReferrals from existing clienteleFacebookOther

6. TERMS AND CONDITIONS

Our integrative therapies are based on our industry-related average tariff as outlined on our website “Terms and Conditions”

In order to secure therapy sessions, physical training sessions, seminars, or the required Residential Recovery Program, full payment is required in advance as outlined on our website “Terms and Conditions”

The client, as explained in paragraph 2, agrees to pay in full their account in advance to Strong for Life Integrative Psychological Therapy practice (hereafter referred to as “THE PRACTICE”) in accordance with the tariff structure determined by THE PRACTICE at the time of the service as outlined on our website “Terms and Conditions”.

For payments, please use this account: Bank: Nedbank, Account nr.: 1211130150, Branch Code: 198765.

In the event that a payment plan is granted, the client further agrees to settle all outstanding accounts within 30 days following the invoice date. The client agrees to pay 2% interest on unpaid accounts every 30 days. In the event that the client does not settle the account and THE PRACTICE deems it necessary to pursue legal action, the client consents to be legally responsible for legal costs and collection costs for psychological services, including attorneys’ fees on a solicitor-client scale, commission, interest, and finding costs.

As defined in paragraph 1 of this contract, the responsible person (hereinafter referred to as “RP”), binds her or him as surety and co-principal debtor, jointly and severally, with the client, the person receiving treatment, for the proper fulfillment of the client’s obligations to THE PRACTICE in terms of this contract.

Both the client and the RP agree that all amounts payable to THE PRACTICE are due by themselves, regardless of any delay or rejection by any medical scheme to pay any claim. THE PRACTICE does not submit claims on behalf of clients to their chosen medical aids.

The client and RP agree that in some instances, it may be necessary to disclose personal information to physicians, healthcare providers, and hospitals to meet the client’s needs. Furthermore, although we will endeavor to handle information with the utmost confidentiality, we cannot accept any liability for third party disclosures of such information. All information disclosed will be handled strictly in accordance with the guidelines outlined in the code of ethics of our profession.

The RP and the client agree to allow THE PRACTICE to share and exchange credit information with any credit bureau or other institution with which they had or might have had financial transactions. In addition, if such information is requested under any circumstances as required by the National Credit Act 34 of 2005.

The RP and the client have chosen the physical addresses above as their domicilium citandi et executandi for service purposes and also agree to notify THE PRACTICE in writing of any changes to their residential addresses. Both parties warrant that they have read and understood the terms and conditions of this contract, in full, and that they consent to be bound by its terms.

I consent to the terms and conditions set forth in this agreement*
YESNO

Please refer to our “Terms and Conditions” on our website before clicking on the button below. I have read and abide by the Terms and Conditions of Use*
Terms and Conditions of use

7. DATA MANAGEMENT – POPIA AND CLIENT CONSENT

I consent to the accuracy of the information I provided*
YESNO

I consent to my data being recorded*
YESNO

I consent to my data being stored*
YESNO

I consent to my data being disclosed*
YESNO

I understand that my information will be treated strictly confidentially*
YESNO

8. THERAPEUTIC RELATIONSHIP AGREEMENT

Over the course of this therapeutic relationship, I agree to the following boundaries:

Treatment visits begin promptly and end promptly as arranged. Please adhere to the given timeframe.

Without an appointment, the therapist will not be able to see you.

Social interaction between our therapists and their clients are not permitted.

I consent to the terms of the therapeutic relationship*
YESNO

If you have concerns, please describe them here