Intake form - Dr Jeanne Meiring

Section 1 - Client information

1. Full Names and Surname as indicated on Identity document/ Birth Certificate *

Preferred name *

Date of birth (d/m/y) *

ID number *

Workplace/ school / University that client is in *

If in school, which Grade?

Physical address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email address *

Phone *

Emergency contact phone number *

Section 3: Parent / Legal Guardian Details if client is below 18 years old (Parent A potentially refers to Mother while B refers to Father)

Relationship status

Parent/ Guardian A: Full names and Surname

Parent/ Guardian A: Cell number

Parent/ Guardian A: Email address

Parent/ Guardian A: ID number

Parent/ Guardian A: Physical address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/ Guardian A: Postal address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/ Guardian A: Occupation and workplace

Parent/ Guardian B: Full names and Surname

Parent/ Guardian B: Cell number

Parent/ Guardian B: Email address

Parent/ Guardian B: ID number

Parent/ Guardian B: Physical address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/ Guardian B: Postal address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/ Guardian B: Occupation and workplace

Signature: I hereby declare that all information above is correct *

Section 4: Payment contract

TERMS OF CONTRACT:
1. I acknowledge that I am personally responsible for the account in respect of both myself and my dependents nominated herein if payment is not received from medical aid by Dr Jeanne Meiring the Psychologist.
2. I acknowledge that my Medical Aid requires the Psychologist to submit an ICD-10 diagnostic code in order for my claim to be processed by them. I hereby grant the Psychologist permission to reflect the appropriate ICD-10 diagnostic code on my invoice/statement.
3. I am aware that I have the right to request the use of a non-disclosure code, but that the possibility exists that my Medical Aid may refuse reimbursement based on this.
4. I choose domicilium citandi et executandi for all notices and processes at the address as given herein.
5. In the event that my telephone number or e-mail address as indicated changes, it remains the responsibility of the client to advise the Psychologist of any changes in contact details.
6. While fully understanding that the Psychologist will try her best to help me resolve my dependent's problem or symptoms, I fully understand that there is no guarantee that the treatment will be successful.
7. I understand that I have the right to terminate treatment whenever I or my child/adolescent wish should I feel that no or inadequate progress is being made.
8. All appointments must be cancelled at least twenty-four (24) hours before the scheduled time otherwise a penalty fee of 50% will be charged of the missed appointment. If a Monday appointment is cancelled it must be done so by 12h00 the preceding Friday.
9. Should I fail to arrive for any scheduled appointment (or not bring my child/adolescent) at the appointed time, I acknowledge that I will be liable for the full fee of that appointment. Please take note that medical aids do not pay cancellation fees.
10. I acknowledge that once appointments have been allocated to me or my dependent, it becomes my responsibility to confirm all appointments in advance.
11. I acknowledge that the Psychologist can bill her time responding to my calls/messages/emails, to her discretion, on business/after-hours rates as applicable.
12. As she strictly work on an appointment - based schedule and as she does not have extra staff to look after young clients after their sessions, parents should kindly arrive on time - invoices will be adjusted and billed accordingly for any minor not being fetched within 10 min after the session has ended.
13. I understand that while the Psychologist takes reasonable steps to prohibit potential contamination with viruses and bacterial infections (e.g. covid-19), that she cannot be held responsible should such an infection occur.
14. The Psychologist will take reasonable steps to secure privacy during online consultations. I understand however that I will not hold her accountable when confidentiality is bridged by an intrusion from another party online or if online sessions result in loss of property.
15. Reports after assessments is an optional additional cost. Reports will be available 7-10 working days after payment has been received.
16. Meetings out of rooms, for example with teachers, will be charged, as per tariff agreement, per 51-60 minutes and increments thereof. Please take note that medical aids do not pay for these meetings.
17 The psychologist does not write progress reports or any other reports on psychotherapy.
18 The purpose of a psycho educational assessment is to gain insight into the learner’s cognitive, academic, emotional, and/or behavioural functioning. Based on the results, clinical recommendations may be made; however, these may or may not include a recommendation for academic concessions.
19. Furthermore, the practitioner cannot guarantee that any specific accommodation (e.g. extra time, a separate venue, a reader or scribe) will be granted, as such decisions lie solely with the relevant educational authorities (e.g. IEB, DBE, school, or university).The final outcome of a concession application is outside the practitioner’s control.

COSTS
1. Fees are claimed from Medical aids via a service provider - Healthbridge.
2. It however is still the client’s responsibility to check the availability of funds as well as whether the aid will compensate for the particular service from their medical aids prior to the intake.
3. Please take note that it is your responsibility to settle claims not covered by medical aid.
4. Payments can be made via EFT (banking details available on request), Card (card facilities available) or Snapscan.

INDIVIDUAL THERAPY (including, couples & family therapy, parent guidance, learner support)
As per Consultation tariff agreement cost

ASSESSMENTS (including, psycho-educational, concessions, school readiness): As per Consultation tariff agreement cost.

Typical duration:
o Intake: 60 minutes
o Feedback: 60 minutes
o Assessment: 3-7 hours

SUBJECT CHOICE/CAREER ASSESSMENT
As per Consultation tariff agreement cost

I accept and understand the payment terms as set out above and agree to this:

Is client above 18 years old? *

Older than 18
Younger than 18

Are parents still married? *

Client signature (if above 18): *

Signature parent A (if client is younger than 18): *

Signature parent B (if client is younger than 18) *

Section 5: Informed Consent

1. Limitations to confidentiality

Following my ethical code, all conversations between me and yourself (individual, parent or child) will remain confidential. There are however exceptions or limitations to confidentiality:

• If I have reasonable suspicion that a child is being neglected, physically abused, sexually abused, subjected to wilful cruelty or mental suffering, or exposed to domestic violence in the home, law requires me to report my suspicion to child protective services. The parents will be notified of this step. • If I feel that you may be in imminent danger of seriously physically harming yourself or you provide me with such indication, I may call the person whom you designate as your emergency contact, a family member, medical or emergency personnel. We will discuss these protective measures and sign an anti-suicide contract. I also expect that should you feel in imminent danger of harming yourself, before doing so, you will do everything you can to contact me and/or seek emergency psychiatric services at a local hospital. • If I receive credible information from you or anyone else leading me to believe that you could be a serious threat of physically harming an identifiable individual(s), I have a legal duty to warn and protect the identified person(s) by communicating the threat of harm to the person(s), to a local law enforcement agency, and/or to others who can assist in protecting the person(s). I also expect that should you feel in imminent danger of harming someone else, before doing so, you will do everything you can to contact me and/or seek emergency psychiatric services at a local hospital. • If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychologist-patient privilege law. I cannot give any information without your (or your legally-appointed representative’s) written authorization, a court order, or compulsory process (a subpoena). • In the event I become debilitated or deceased, a trusted colleague will have access to your records so that you can be contacted, informed of my status, offered support, and be provided with any proper referrals.

2. Confidentiality with minors

If I am seeing your child who is under the age of 18 on an on-going basis or within an assessment situation, then much of what he/she talks to me about is kept private between us except for the above exceptions whereupon I will have to let you know (i.e., parents/guardians) for help. Privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement is also essential. During treatment I typically provide parents only with general information about the progress of the treatment and the child’s attendance at scheduled sessions. I may also speak to you about what your child has discussed with me if I feel that it would be essential for his/her welfare and would help the family situation. Any other communication will need the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents/guardians of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

3. Sharing information with third parties
During and after an assessment I might feel that it would be necessary to communicate with a third party (e.g. school, teacher or other professional). I would however have to obtain your written consent before I do this. The written report received after the completion of an assessment is also the exclusive property of the client and parents and if they wish to share the information with any other party it will be done at own discretion and risk. Written consent is also necessary when a request is made to send a report electronically (email or fax) by the client or parents.

4. POPIA consent
I also hereby give consent that my personal information provided by me in the submitted form with medical aid details, may be processed and stored in accordance with the Protection of Personal Information Act. I further give consent that this information (to the extent that it may be necessary) may be shared with my medical aid, the Healthcare professional's accounts department, other medical service providers and in the case of non-payment of my account, debt collectors and/or attorneys.

5. Parental consent minors
Please note that informed consent needs to be obtained from BOTH living biological parents/ legal guardians before services can be rendered to a minor. Please inform us should this not be possible.

6. In cases where parents are divorced or separated, it is the responsibility of the contracting parent (i.e. the parent who initiates and consents to the assessment) to ensure that all necessary legal guardianship rights and obligations are upheld.

7. Unless a court order explicitly states otherwise, both legal guardians typically retain equal rights to access educational and psychological information about their child. The practitioner remains neutral in parental disputes and cannot withhold the assessment report or feedback from the other parent if they share legal guardianship, regardless of who paid or the assessment. By signing this agreement, you acknowledge that assessment information may be shared with both parents where legally applicable.