Consent Form | Soulful Psychology

1

Personal details

So that we can contact you and keep accurate records.

Full name *This field is required.

Date of birth *This field is required.

Phone number *This field is required.

Email address *This field is required.

Residential address

2

Emergency contact

Someone we may contact in an emergency.

Contact name *This field is required.

Relationship to you *This field is required.

Contact phone number *This field is required.

3

Medical aid

Optional — complete only if you intend to claim.

Medical aid scheme

Plan / option

Membership number

Main member name

4

About your visit

Share as much or as little as you’re comfortable with.

Service

Referred by (if applicable)

What brings you to therapy? *This field is required.

Have you had therapy or counselling before?If yes, roughly when and for what.

Are you currently taking any medication or receiving any other treatment?Optional. This helps us provide safe, appropriate care.

5

Agreement & consent

Please read the information below carefully.

Confidentiality

Everything you share in therapy is treated as confidential. Information will not be shared with anyone without your written consent, except where the law or professional ethics require it. These limited exceptions include:

where there is a serious risk of harm to yourself or another person;
where there is a reasonable suspicion that a child or vulnerable person is being harmed or neglected;
where records are required by a court order or by law.

Appointments & cancellations

Please give as much notice as possible if you need to cancel or reschedule. Late cancellations and missed appointments may be charged in line with our cancellation policy.

Fees & payment

You are responsible for the payment of all session fees. Where you claim from a medical aid, any amounts not covered by your scheme remain your responsibility.

Your personal information (POPIA)

Soulful Psychology collects and keeps your personal information to provide therapy services, keep clinical records and process payments. Your information is stored securely, used only for these purposes and handled in line with the Protection of Personal Information Act (POPIA). You may request access to, or correction of, your personal information at any time.

Electronic communication

By providing your phone number and email address, you agree that we may contact you through these channels about appointments and your care. Email and messaging are not completely secure; please let us know if you would prefer a different way of being contacted.

Your rights

Taking part in therapy is voluntary. You may ask questions about the process at any time and may end therapy whenever you choose.

I have read and understood the confidentiality information, including its limits. * I agree to the appointment, cancellation and payment terms. * I consent to Soulful Psychology collecting and processing my personal information as described above (POPIA). * I consent to receiving communication about my appointments and care by phone and email. *

6

Signature

Typing your full name below acts as your signature.

Full name (signature) *This field is required.

Date *This field is required.