SUSAN EKSTEEN (Therapist)
CLIENT NAME/S: ________________________________________________
1. I am bound by the Codes of Ethics and Practice of the Health Professions Council of South Africa (HPCSA). https://www.hpcsa.co.za
2. Subject to me being satisfied that your problem is one that can be alleviated by my skills a Registered Counsellor and Imago Relationship Therapist as well as South African Institute of Hypnotism Certified, Parts Therapy Hypnosis Facilitator, I agree to offer you the sessions that you require. This is my commitment to you. You may terminate therapy without further cost at any time you wish.
3. The normal duration of each session is one and a half hour, although I reserve the right to amend that time for therapeutic reasons. If for any reason you are late for a session, I will see you for the duration of the remainder but will be unable to work beyond the allotted time as this will disrupt the time for other clients who may be waiting.
4. It is understood that sometimes sudden events, such as emergencies, happen, that may make it necessary for clients to cancel their appointment last minute or fail to attend and are unable to provide notification. On these occasions it is at the therapist’s discretion if a fee will be charged. In general however, if you fail to give less than 24 hours’ notice of your intention to cancel or reschedule an agreed therapy session or if there is a repeat pattern of cancellations or not showing up, I reserve the right to charge in full for that session.
5. The cost for each session will be R____________ per session. Payment should be made at the end of each session. A CASH PAYMENT IS REQUIRED FOR THE FIRST CONSULTATION. EFT payments can be made from the second session onwards. There are no card facilities. Please note for EFT payments, BANK DETAILS will be supplied on request.
6. If agreed payments for therapy are not being paid then I reserve the right to terminate therapy.
7. The practice does not claim from any client’s medical aid. An invoice will be supplied which can be used by the CLIENT to claim back fees.
8. As part of my code of ethics set out by the HPCSA and SAIH, I am required to carry out continuing professional development, and to engage in regular on-going clinical supervision. This is to ensure an ethical and professional service to clients. I may discuss your case in supervision but would not use any identifying details.
9. If I wish to record a session I will ask you first. If you wish to record the sessions yourself you may do so without cost, of course.
10. Confidentiality will be maintained within the codes of ethics and legal requirements. Confidentiality may be breached if I consider there is a risk you may harm yourself or others, or if I am legally required by a court of law subpoena. In such exceptional circumstances, where there is concern for your well-being or that of others, it may be necessary to seek help outside the therapeutic relationship. In such an event where I am considering breaching confidentiality, you will normally be consulted first.
11. In the case of a disclosure concerning acts of terrorism, vulnerable adult or child protection issues, or drug trafficking; confidentiality will be breached and such disclosures will be passed onto the relevant authority without delay. Due consideration should be exercised before disclosing anything of a previously unreported criminal nature, as I am obligated to contact relevant authorities.
12. Our therapeutic relationship will remain a professional one at all times, the boundaries of which (such as contact outside of our sessions) can be agreed between us during our sessions.
13. Notes may be taken during and after each session, which will be kept in accordance with the HPCSA regulations. These notes will be securely stored. I will discuss the disposal, retention or otherwise of any such notes at the end of our engagement. They are disclosed to no one other than the clinical supervisor, unless required under a court of law subpoena. You have the right to inspect your records should you so wish, and this request will be fulfilled during a therapy session.
14. Endings – Counselling can at times be challenging, demanding, frustrating and emotional. You might find this process difficult, and feel the need to end therapy. Your feedback on the process will be asked for at the end of each session and if you feel unhappy with any aspects of the treatment being offered, please do try and communicate this verbally. This gives us both the chance to address and resolve issues. In the normal course of events you will probably know when you are ready to stop the sessions, and we will agree together on the work we need to do to prepare for this.
15. I will not suddenly or without warning terminate our contract, except in exceptional circumstances, such as arriving under the influence of alcohol or non-prescribed medication, including recreational drugs/street drugs.
16. You will be notified of any holidays to be taken by myself well in advance. However, there may be occasions when sessions may be cancelled because of illness or because of attending training sessions or meetings. I will try to give you as much notice as possible of any cancellation, and will offer an alternative time. Therefore, please notify any change in contact details.
17. If you might need a report or any written documents from me, it will be charged at the same per 90 minute consultation rate as a therapy session. Payment needs to be made before the documentation would be supplied.
18. In the event of you being unhappy with the service you receive, please discuss this with me. If you feel unable to do so or do not receive satisfactory resolution, then you have the right to complain to my professional body, the HPCSA.
19. I acknowledge my understanding of this document and that the information provided is accurate and complete to the best of my knowledge.