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NEW CLIENT INTAKE

Basic information

Preferred Pronoun

Referral Information

Mental Health History

Have you been diagnosed with any mental health conditions?
Yes
No
Are you currently taking any medications for mental health conditions?
Yes
No
Have you ever been hospitalised for mental health reasons?
Yes
No
Do you have a history of substance abuse or addiction?
Yes
No

Accessibility and Support Needs

Do you have any disabilities or medical conditions you would like me to be aware of to better accommodate your needs?
Yes
No

Lifestyle and Background Information

Do you have children?
Yes
No
Do you feel you have a support system (friends, family, community)?
Yes
No

Additional Information

Cancelation Policy

To provide the best service and accommodate all clients, we require advance notice for any changes to your appointment. Our cancellation policy is as follows:

  • 24-Hour Notice: If you need to cancel or reschedule your appointment, please provide at least 24 hours' notice. Cancellations or rescheduling requests made less than 24 hours before your scheduled appointment time will incur a cancellation fee.

  • Cancellation Fee: Appointments cancelled with less than 24 hours' notice or missed appointments (no-shows) will be charged in full for the appointment. This fee is necessary to cover the time reserved for your session.

  • Emergency Cancellations: I understand that emergencies and unforeseen circumstances can arise. In such cases, please contact me as soon as possible to discuss your situation. I may waive the cancellation fee at my discretion for genuine emergencies.

  • Repeated Cancellations: Clients who repeatedly cancel or miss appointments may be required to prepay for future sessions to secure their appointment times.

  • How to Cancel: To cancel or reschedule your appointment, please call us at [insert phone number here] or email us at [insert email address here]. Please leave a detailed message if you reach our voicemail.

By scheduling an appointment, you acknowledge that you have read and understand our cancellation policy.

Payment Policy

To ensure a smooth and efficient process, please review my payment policy below:

  • Payment Due at Time of Service: Payment is due at the time of your appointment unless prior arrangements have been made. I accept [list accepted payment methods, e.g., cash, credit/debit cards, bank transfers, etc.].

  • Rates and Fees: My current rates and fees are as follows:

    • [List your service rates and any additional fees]

    • [Include any package or bundle options, if applicable]

  • Invoices and Receipts: Upon request, I will provide invoices and receipts for all services rendered. If you require detailed billing statements for insurance or reimbursement purposes, please let me know in advance.

  • Late Payments: Payments not received within [insert number] days of the appointment will incur a late fee of [insert amount or percentage]. Continued failure to settle outstanding payments may result in the suspension of services until the account is brought current.

  • Prepaid Packages: For clients who purchase prepaid packages or bundles, payments must be made in full before the first session. Prepaid sessions are non-refundable but may be transferred to another individual or rescheduled, provided they adhere to my cancellation policy.

  • Medical Aid: my services cannot be claimed from medical aids. Clients are responsible for the full payment of all services rendered.


  • Financial Assistance: I understand that financial situations can vary. If you are experiencing financial hardship, please discuss it with me to explore potential payment plans or sliding scale options.

  • Contact Information: For any questions or concerns regarding payments, please contact me at +27 82 066 3988 or amy.shamanictherapy.co.za.

By scheduling an appointment, you acknowledge that you have read and understand my payment policy.

Consent

Confidentiality and Data Privacy Statement

Your privacy is of utmost importance to us. All personal information provided in this form will be kept confidential and secure in accordance with the Health Professions Council of South Africa (HPCSA) guidelines and the Protection of Personal Information Act (POPIA).

  • Confidentiality: All information shared during our sessions is confidential and will not be disclosed to any third party without your explicit consent, except where required by law or if there is a risk of harm to yourself or others.

  • Data Privacy: Your data will be stored securely and used only to provide you with the best possible care. We will take all necessary steps to protect your information from unauthorized access, loss, or misuse.

  • Access to Records: You can access your records and request corrections to any inaccurate information. If you have any concerns about your privacy or the confidentiality of your information, please feel free to discuss them with us.

  • By completing this form, you acknowledge that you understand and agree to these terms. If you have any questions or need further clarification, please contact me!

LAST STEP:
Informed Cosent Form

If you're feeling that form fatigue, you can always come back to complete this one later.
You'll find it in the menu under forms. It might be a good idea to push through, however, because it's just a quick read and confirm.

Relationship Coaching Informed Consent Form

Uncoupling Coaching Informed Consent Form

Professional Coaching Informed Consent Form

SomatoSensual Therapy Informed Consent Form

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