Intake & consent form - Therapy (adults)

Medical aid details

Please note that Dayne Williams operates as a cash practice and therefore the patient (or parent) is responsible for payment. Once payment has been made you will be issued with a receipt which can be used to claim back from medical aid. Please consult your medical aid first to ensure funds are available for psychological sessions.

Details of person responsible for account

Details of patient:

Consent form

I hereby give permission for Dayne Williams to interview, assess and provide treatment in accordance with the guidelines and terms mentioned below:
2. Acknowledge that all private information collected about you will be treated as highly confidential; no information will be disclosed without your consent, unless required to do so by the Court of Law.
3. Acknowledge that I/we gave my/our consent, willingly and without being unduly influenced to do so by any person.
4. Give consent to communicate information and reports (where applicable) via email and/or Whatsapp messaging platform.
Please use mouse (pc) or finger (phone/tablet) to sign above