Dr John-Eduard Bosman

CLIENT INFORMATION, TERMS AND CONDITIONS, AND CONSENT DOCUMENT Welcome to my practice. This document will provide you with the essential information regarding administration, fees, payments, and ethical rules. Please read it with care even though it will take a couple of minutes – it contains information that will be important and useful to you. By signing this document, you agree to my full Terms and Conditions. Evaluation Phase For me to render a service to you I need to do a proper evaluation. In the course of this evaluation, I will ask you a number of questions about your situation, personal history, and relationships. I will ask you to complete a questionnaire about yourself. It is also sometimes valuable to interview other people who know you to obtain additional information. I will only do so with your consent. Therapeutic Phase Counseling is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. The success of therapy is influenced by several factors. One of the most important factors is the degree to which clients take responsibility to bring about change. No therapist can give a guarantee that therapy will be successful. Confidentiality 1. Except for certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. I will always act to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you. 2. I am required by law to inform the relevant authorities of suspected child abuse, elder abuse, or abuse of people with disabilities. If there is a threat of bodily harm to you or others, I may break the confidentiality of communications. I will make reasonable efforts to resolve these situations before breaking confidentiality. 3. Sessions may be audiotaped or videotaped and may be used in supervision or to record client progress. All materials concerning clients are confidential and every effort to maintain confidentiality is assured. Furthermore, no demographic data will be used. 4. Information obtained in sessions may be used for research purposes, presented anonymously at professional meetings and/or published in journals/textbooks. At no time will any identifying information regarding the client be used and every effort to maintain confidentiality is assured. 5. If you elect to communicate with me via email at some point in our work together, please be aware that email is not completely confidential. Any email I receive from you, and any responses that I send to you, may be kept in your treatment record. Record-keeping I keep written records of therapy sessions. Under the provisions of the Promotion of Access to Information Act 2 of 2000, you have the right to a copy of your file at any time or I can prepare a summary for you instead. I maintain your records in a secure location that cannot be accessed by anyone else. Termination Either you, or I, can terminate therapy at any stage. I will only terminate therapy in consultation with you and in a professional accountable way. Contacting me Please use only phone, sms or WhatsApp to contact me. If you need to contact me between sessions, the best way to do so is by phone, SMS or WhatsApp. Direct email to admin@drjohnbosman.com is second best for quick, administrative issues such as changing appointment times. I do not answer phone calls from clients during sessions. Appointments Appointments must preferably be made by using my online booking app at: https://book.heygoldie.com/Dr-John-Bosman . If you would like to cancel an appointment, you need to do so at least 24 hours before the time. Fees and Payment Please note: All first appointments must be paid via EFT at least 48 hours before the appointment. Once your appointment is confirmed, please make payment at least 48 hours in advance. Follow up appointments are payable in cash, card, EFT or approved Medical Aid either prior to or at the appointment. You may receive a statement around the end of each month, or you may request an invoice for processing a claim with your Medical Aid. Consultation Fee Structure: Please take note that my fees are cash fees and may be more than your Medical Aid fee for the service provided by me. It is possible that only a portion of your fee might be covered by your medical aid. You can contact your specific medical aid in advance to familiarize yourself with their applicable rules. By signing this document, you acknowledge that you have been informed of the fact that the fees charged may be more than medical aid rates. Couple Counseling • Initial Consultation: 75 to 90 minutes @ R880 (payable via EFT at least 48 hours before appointment). • Further Sessions: 60 to 75 minutes @ R800 OR • 75 to 90 minutes @ R920. Individual Counseling • Initial and follow up sessions: 50 to 61 minutes @ R700.  The client hereby agrees to pay for all the specified services according to the above fee structure. _______ Initial Outstanding accounts may be referred to our attorneys for debt collection. You will be held responsible for all legal costs relating to the debt collection such as commission and fees levied by the attorney. Please consult with Dr Bosman should you wish to make arrangements for payment of your account. BANKING DETAILS: Dr J E Bosman: FNB Cheque Account Number 62802447905 Branch Code 250655 Woodbridge My practice will process follow up consultations through your Medical Aid where applicable. However, you will remain responsible for all short payments by the Medical Aid. Short payments are payable before the end of the month in which the claim was processed. Appointments not cancelled at least 24 hours prior to the appointment, will be charged for in full. Please note that medical aids do not cover missed appointments, therefore this amount will be for your own account. If you are late for an appointment, I cannot extend the time of the session. Thank you for making use of my services and giving me the opportunity to work with you. Client Consent to Therapy I have read this Client Information, Terms and Conditions, and Consent document, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I consent to the use of a diagnosis in billing, and to release of that information and other information necessary to complete the billing process. I agree to pay the set fee per session. I consent to the keeping of written, video and/or audio records. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me. I agree to undertake therapy with Dr John-Eduard Bosman. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made by Dr Bosman. Signed:_____________________________ Witness: _______________________________ Date: ______________________________