Client Intake Form

In accordance with the Protecting Personal Information Act (POPIA), a service Agreement between the service provider and client is mandatory. Moreover, professional Family Law Mediators must comply with the South African Association of Mediators’ (SAAM) Code of Conduct and Mental Health Practitioners with the Health Professional Council of South Africa’s (HPCSA) Code of Conduct, especially psychologists, psychotherapists, and counsellors.

Accordingly, our  Client Intake Form serves as a binding Legal Agreement between the client and service provider (Juanitte Pieterse: Psycho-Legal Consultancy, Family Law Mediation, Forensic and Clinical Psychological Practice) and sets forth both parties’ responsibilities and expectations, ensuring that each party understands clearly their rights and responsibilities, thus promoting a transparent and trusting collaborative and professional relationship. Additionally, it specifies how data will be collected, used, and stored in compliance with relevant laws.

To ensure availability:

All reservations must be made in advance as specified in our Terms and Conditions under the heading “OUR FEES”.

For services that require a quotation, please contact us at info@sfl-interactivetherapy.com to obtain a quotation before submitting the Client Intake Form.

A copy of the full payment in PDF format must be submitted along with the Client Intake Form.

Banking Details:

Nedbank: 1211130150. – As a reference, please use the following format: current year/initials and Surname, e.g. 2025/JM.vdMerwe

Contract and Security of information: 

This website’s forms have been secured with an accepted and standard form of web technology called Let’s Encrypt, ensuring the safety of information transferred.

The following section contains the Client Intake Form, which constitutes the contract between the service provider and the client.

“*“ indicates mandatory fields

    1. CLIENT DETAILS

    How do you want to be consulted?*

    What kind of service do you require?*

    Which is your preferred appointment timeframe?*

    Which is your preferred weekday availability?*

    What is your preferred daytime availability?*

    How soon would you like to proceed?*

    Please describe briefly your situation and the service that you require, including estimated frequency and duration of the service (days, weeks, months, etc.)*

    2. CONTACT PERSON

    3. PRIMARY PERSON RESPONSIBLE FOR PAYMENT

    I consent to the accuracy of the information I provided*

    4. METHOD OF PAYMENT: Currently, only EFT payments are accepted*

    5. REFERRAL

    How did you hear about us?*

    6. TERMS AND CONDITIONS

    6.1 As a private practice, we do not accept insurance coverage under any medical health plan, all fees are the client’s responsibility.

    6.2 All professional fees and consultation fees associated with Juanitte Pieterse – Psycho-Legal Consultancy, Family Law Mediation, Forensic and Clinical Psychological Practice are based on industry-specific average tariff as outlined on our website “Terms and Conditions” under the section titled “Our Fees”.

    6.3 In order for Juanitte Pieterse to provide meaningful and effective support, she requires her clients commit exclusively to her Psycho-Legal Counsel, Clinical Psychology treatment plan and/or Family Law Mediation program. She does not provide services to clients currently receiving any of the services mentioned above from other professionals outside of her Practice.

    6.4 In order to secure your consultation(s) and/or the required service program, full payment is required in advance as outlined on our website “Terms and Conditions” under the section titled “Our Fees”.

    6.5 The client, as stipulated in paragraph 1, agrees to pay in full their account in advance to Juanitte Pieterse – Psycho-Legal Consultancy, Family Law Mediation, Forensic and Clinical Psychological 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” under the section titled “Our Fees”

    6.6 Cancellations must be submitted in writing via email to finances@sfl-integrativetherapay.com in advance according to the prescribed notice period as outlined on our website “Terms and Conditions” under the section titled “Our Fees”.

    6.7 THE PRACTICE do not accept cancellations via Phone, WhatsApp, SMS or text message.

    6.8 In the event the client fails to cancel his/her scheduled consultation(s) and/or the required service program without the required notice period as outlined on our website “Terms and Conditions” under the section titled “Our Fees”, the full amount will be charged to the client’s account.

    6.9 THE PRACTICE are willing to make arrangements for clients who cannot make full payment in advance of the service, provided they pass all necessary credit bureau screenings.

    6.10 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 15% 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.

    6.11 As defined in paragraph 1 and 2 of this contract, the responsible person (hereinafter referred to as “RP”), binds him/her as surety and co-principal debtor, jointly and severally, with the client, the person receiving services, for the proper fulfilment of the client’s obligations to THE PRACTICE in terms of this contract.

    6.12 Both the client and the RP agree that all amounts payable to THE PRACTICE are due by themselves.

    6.13 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.

    6.14 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.

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

    7. DATA MANAGEMENT – POPIA AND CLIENT CONSENT

    By signing below, the client consent to THE PRACTICE and its designated Administrator to process the client’s personal data according to the following legitimate reasons:

    7.1. Upon the client’s consent, the client understand that his/her personal information will only be used for the purpose for which it was collected, that the information will be retained for a period of time that is necessary and required by law, and that the client is entitled to view the information at any time and to request the correction or deletion of his/her personal information held by THE PRACTICE.

    7.2. The Client understand that he/she may withdraw his/her consent at any time by using the THE PRACTICE relevant Data Subject Consent Withdrawal Form.

    7.3. THE PRACTICE has the client’s express consent to collect and process the client’s information for the purposes of providing the client with Psycho-Legal and/or Clinical and/or Forensic Psychology and/or Family Law Mediation consultation services.

    7.4. THE PRACTICE and its Administrative Staff have the client’s express consent to accessing the client’s personal information contained in the client’s record, which may include psychological and/or litigation notes for processing documentation, or performing any other administrative function as requested by the client’s professional health care providers and/or legal counsel.

    7.5. It is the client’s express consent that THE PRACTICE may use the client’s personal information to contact the client in person, by telephone, by email, by video call, by WhatsApp, or by any other method.

    7.6. It is the client’s express consent that THE PRACTICE may disclose any of the client’s personal health and/or confidential information to JP Psycho-legal associates that may provide the client with health care or legal services, as well as referential professionals.

    7.7 The client and RP agree that in some instances, it may be necessary to disclose personal information to physicians, medical and mental health care professionals, and legal experts to meet the client’s needs.

    7.8 Furthermore, although THE PRACTICE will endeavour to handle information with the utmost confidentiality, THE PRACTICE 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 THE PRACTICE profession.

    7.9. The client expressly consent to THE PRACTICE submitting any outstanding accounts to any third-party debt collection agency that may collect any outstanding accounts that are unpaid and due by the client.

    7.10 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 to, if such information is requested under any circumstances as required by the National Credit Act 34 of 2005.

    The client consent to his/her data being recorded*

    The client consent to his/her data being stored*

    The client consent to his/her data being disclosed*

    The client understand that his/her information will be treated strictly confidentially*

    8. CONSULTANT-CLIENT PROFESSIONAL RELATIONSHIP AGREEMENT

    Over the course of this CONSULTANT-CLIENT relationship, the Client agree to the following boundaries:

    8.1 Consultation appointments begin promptly and end promptly as arranged. The client pledge to adhere to the given timeframe.

    8.2 Without an appointment, THE PRACTICE Consultant, will not be able to see the client.

    8.3 The client understand that it is his/her legally binding responsibility not to misrepresent himself or herself untruthfully or act violently during consultations.

    8.4 Social interaction between THE PRACTICE and clients are not permitted.

    The client consent to the terms of the Consultant-Client Professional Relationship Agreement*

    If you have any concerns, please describe them here

    Please upload your proof of payment as a PDF*