Client Bookings and Billing Consent form
​Psycho-Social-Counselling OR Trauma Counseling Registered client bookings call 010 020 242
Ask your employer to book your session today!

Find the billing policies and procedures as well as costs and payment options below.

Are you constantly feeling stressed or anxious due to events beyond your control?

Perhaps consider how Mental Health Therapy can be beneficial to your growth and personal development.

Mental Health Therapy provides
1. Mental Health screening
2. Stress and Anxiety Counseling
3. Mental Health Therapeutic sessions
....with the aim to make sense of your emotions for personal growth and development.

My work involves a great deal of activity around Stress and Anxiety and understanding the emotional challenges people face in their daily lives. If you are constantly feeling stressed or anxious then this is the perfect time for you to focus on yourself.

All Hybrid Academy Learners must also submit this form, select option below.

Hester de Lange
Mental Health Therapist

http://www.familycorner.co.za/
46 Royal Oaks, Villebois Mareuil Drive

Address link: https://g.page/the-family-corner?share

Any information shared will be kept private and confidential.

GO HERE FOR more information regarding the Wellness and Mental Health Assessment & Counseling Presentation:

https://docs.google.com/presentation/d/16Zz5jQoB6FpRftf-_LPqM7gPV6C5sRUHw0GTt5vawrg/edit?usp=sharing

COMPLETE THE FORM BELOW BEFORE YOUR FIRST SESSION CAN COMMENCE!

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Email *
NAME AND SURNAME: *
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NAME AND SURNAME OF PERSON REQUIRING THERAPY SESSION: *
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I hereby give consent to have my mental health assessed by the therapist. *
I understand that the screening and profiling is not a medical diagnosis and does not take the place of a medical practitioner. The assessment is used to assist with stress and anxiety recommendations. I understand that the practitioner has received formal training in Mental Health.
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YOUR CONTACT NUMBER: *
YOUR DATE OF BIRTH: *
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HEALTH RECORDS: *
HAVE YOU OR ANYONE IN YOUR FAMILY SUFFERED AN ILLNESS IN THE LAST 6-MONTHS?
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IF YES, PLEASE GIVE DETAILS OF ILLNESS:
ANY PAST MEDICAL OR MENTAL HEALTH HISTORY OR SURGICAL PROCEDURES? *
ANY CURRENT MEDICAL CONDITIONS/MEDICATIONS? *
WHICH ONE OF THE FOLLOWING CAN BE SAID IMPORTANT REGARDING YOUR THERAPY SESSION: *
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Required
What times will suit you best to attend your therapy sessions? *
Online therapy is usually fairly affordable and convenient. Since you will be attending therapy sessions online in the comfort of your own home, you can often schedule your therapy sessions for times that are the most convenient for you. Article regarding pros and cons of online therapy: https://www.verywellmind.com/advantages-and-disadvantages-of-online-therapy-2795225
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As per the time selected above, which days will suit you best for Therapy sessions? *
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BILLING POLICY AND PROCEDURE DETAILS FOR SESSIONS: *
The statement will be sent to your email address given above that can be used for your yearly tax submissions and claim from medical aid if they cover counseling.
Required
Private Clients - Your Invoice will be sent to you, submit it with your yearly tax return or to your medical aid if they cover counseling. *excludes Registered clients as indicated above. *
Bank: First National Bank Account Name: GEThybrid (PTY) LTD Account Number: 62746834391 Branch Code: 205609 Type of Account:- Cheque Please ensure that you send your proof of payment to 082 843 7247 Reference name and surname. *Booking will be confirmed upon receipt of POP
Required
Snapscan.
If you have a banking app then you can use your banking app to do a direct payment with snapscan. Simply open your banking app, go to payments, Scan to pay and scan this QR code. Enter your amount and click on pay now.
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How did you find us? *
Waiver: Since I am not a medical doctor, I do not diagnose, neither do I advise you to stop taking any chronic medication prescribed by your doctor. I hereby state that I will not share your information without the written permission of yourself, or the legal guardian in case of a child under the age of 18.
Hester de Lange
Family Mental Health Therapist
Hester de Lange Family Mental Health Therapist
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