This secure form takes approximately 8–12 minutes. All information is strictly confidential and sent directly to our practice.
HPCSA Registered
Strictly Confidential
POPIA Compliant
1
Service
2
Your Details
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Client Info
4
Background
5
Consent
Let's get started
Tell us about the service you're looking for and how you'd like to pay.
Select a service
Please select a service to continue.
Who is the client?
Please indicate who you are booking for.
Payment preference
Please select a payment method.
Step 1 of 5
Your details
The account holder is the responsible party for billing and correspondence.
Personal information
Medical Aid Information
Medical aid may be claimed from your first session, provided funds are available and your scheme pre-authorises the service. The account holder remains solely responsible for any rejected or declined claims, regardless of reason.
Emergency contact
Step 2 of 5
Client details
Please provide information about the person attending sessions.
Client particulars
If client is a scholar, please include grade and school name.
Partner 1
Partner 2
Please add all family members who will be attending sessions (up to 6).
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Clinical Supervision
You are booking supervision for yourself. Account holder details from the previous step will be used as client details. Continue to the next step.
Step 3 of 5
Background information
Your answers help us prepare for your first session and ensure the best possible fit.
Psychotherapeutic history
Assessment history
Current concern
Reason for assessment
Screening information
Supervision details
Health & medical history
This helps us tailor our approach and ensure your safety. You may write "None" if not applicable.
Wellbeing & Safety Check-in
Thank you for sharing — this takes courage. Your safety matters deeply to us. If you are in immediate distress, please contact the SADAG Suicide Crisis Line: 0800 567 567 (available 24/7). Our team will follow up with you as a priority.
Your answer helps ensure we are best prepared to support you safely. This information is strictly confidential unless there is immediate risk of harm, as required by law.
Step 4 of 5
Informed consent
Please read the following carefully before signing. Scroll down to read all sections.
Scope of Practice
Neo-Psych Services is a registered psychological practice. Our registered Educational Psychologist holds HPCSA Registration No. PS 0150754, registered under the Health Professions Act (Act No. 56 of 1974). Neo-Psych Services provides psychoeducational assessments, screenings, consultation, individual therapy, couples and family therapy, and clinical supervision. Our clinical approach is psychodynamically informed — exploring emotions, perceptions, and past experiences to better understand and navigate present and future behaviour.
Confidentiality
The client has the absolute right to confidentiality regarding therapy and assessments. All information disclosed in session is strictly confidential. Per the National Health Act (Act No. 61 of 2003), the South African Constitution (Act No. 108 of 1996), HPCSA Rule 13, and the Mental Health Care Act, 2002 (Act No. 17 of 2002), information may only be disclosed:
At the instruction of a court of law;
With the express consent of the client (above the age of 12 years, in accordance with the Children's Act, 2005, Act No. 38 of 2005);
With written consent of a parent or guardian for a minor under 12 years; or
Where disclosure is in the public interest — where the individual poses a risk of harm to themselves or others, or where acts of abuse against a child must be reported as mandated by law.
Important (minor clients): In the case of divorced, separated or geographically separated parents, consent for a minor is required from both legal parents/guardians (maternal and paternal) before any consultation or assessment may commence. Our psychologist's role is strictly limited to providing clinical treatment and may not be called upon in legal disputes concerning custody arrangements.
Record-Keeping
Professional treatment records are maintained securely in accordance with the National Health Act (Act No. 61 of 2003). Clients have the right to access their file at any time, request corrections to factual errors, and request that records be shared with other healthcare providers. Records are kept in a secure, encrypted location not accessible by any third party. Assessment reports and therapy notes are for the client/guardian's information only and may not be used for legal action, except within the confines of a formally commissioned Medico-Legal Assessment process.
Right to Withdraw Consent
The client or account holder has the right to withdraw consent to treatment at any time. Withdrawal of consent must be communicated in writing to Neo-Psych Services. Withdrawal does not affect the validity of consent given prior to withdrawal. Outstanding accounts remain due and payable upon termination of services.
Complaints & Regulatory Oversight
Should you have any concern regarding the professional conduct of a registered practitioner, you have the right to lodge a formal complaint with the Health Professions Council of South Africa (HPCSA) at: 0861 242 424 or hpcsa.co.za. Neo-Psych Services encourages clients to first attempt resolution directly with the practice before approaching a regulatory body.
Payment & Cancellation Policy
Payment may be made via EFT, cash (debit card), or medical aid.
Medical Aid: Medical aid may be claimed from your first session, provided your scheme pre-authorises the service and you have available funds. Claims are subject to your scheme's benefit rules and authorisation processes. The account holder remains fully responsible for settlement of the account in all instances — including where the medical aid declines, rejects, or partially pays any claim, for any reason whatsoever. Unpaid accounts may be referred to a third-party debt collection agency at the account holder's cost.
Cancellation: Cancellations or rescheduling must be done at least 24 hours before the session. Failure to provide adequate notice (without a valid, documented reason) will result in a charge of 50% of the full session rate. Repeated no-shows may result in termination of the therapeutic relationship.
Privacy & Communication Policy
The client/account holder consents to the use of WhatsApp Messenger (or similar instant messaging platforms) for day-to-day appointment-related communication. Telephonic consultations exceeding 30 minutes will be billed accordingly.
Online sessions are conducted via a secure video platform. While all reasonable efforts to maintain privacy are undertaken, confidentiality on digital platforms cannot be fully guaranteed — it remains the client's responsibility to ensure privacy and security in their chosen session environment.
All documents shared from this practice containing client-related information will only be transmitted digitally (via encrypted email) or provided as a hard copy to the client or parent/caregiver. Disclosure to any third party requires a signed disclosure and consent document.
All information collected and stored by Neo-Psych Services is managed in strict accordance with the Protection of Personal Information Act, 2013 (POPIA, Act No. 4 of 2013) and will be used solely for the purpose of delivering psychological services.
Consent to Psychological Services
By completing and signing this form, the client/account holder confirms they have read, understood, and agree to be bound by all terms contained in this document throughout their professional relationship with Neo-Psych Services. This consent form constitutes a binding agreement between the client/account holder and Neo-Psych Services.
Please scroll up to read the full consent document before checking the boxes below.
Please check all consent boxes to continue.
Is the client a minor (under 18)?
Please indicate if the client is a minor.
⚠ For minor clients, consent from both legal parents/guardians is required prior to any consultation or assessment. Please provide their details below.
Digital signature
By typing your full name below, you confirm that you have read and understood this entire document, and that you agree to be bound by its terms throughout your professional relationship with Neo-Psych Services.
Please enter your full name as a digital signature.
Please select your signing capacity.
Step 5 of 5
Thank you, there.
Your intake form has been successfully submitted. A copy of your submission summary is ready below. Our team will review your information and be in touch within 1–2 business days.
01
We Review
Your intake is reviewed within 1–2 business days to understand your needs and confirm the right fit.
02
We Confirm
The Neo-Psych team will reach out via WhatsApp or email to confirm your appointment and discuss any next steps.
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Your Booking Link
A personalised booking link is sent so you can choose a session time that works for you.
Confidentiality: All session information is strictly confidential per HPCSA Rule 13, National Health Act (No. 61 of 2003), Mental Health Care Act (No. 17 of 2002) and Children's Act (No. 38 of 2005). Disclosure only under court order, client consent, or imminent risk of harm. Payment & Cancellation: Medical aid may be claimed from Session 1 subject to scheme pre-authorisation and available funds. Account holder is fully responsible for all rejected/declined claims. 24-hour cancellation notice required or 50% charge applies. Privacy: WhatsApp/email used for appointment communication. All records managed per POPIA (Act No. 4 of 2013). Right to Withdraw: Client may withdraw consent at any time in writing. Complaints may be directed to HPCSA: 0861 242 424.
