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Informed Consent for Therapeutic Consultation
(Individual, Couple, Group, and Family)
Anthony Hawthorn, BSocsci (Hons) Clinical Social Work, MBL
I am a registered Social Worker in private practice. Professional registration number 10-23366. In applying to the board of health care funders (BHF), I required the South African Council of Social Services (SACSSP) endorsement to operate in private practice. My current BHF number is 089 000 0636746.
As part of the therapeutic process, the council requires me to keep notes containing personal information shared with me in the therapeutic process. I, therefore, have a responsibility to obtain your informed consent to do so.
Protection of your rights and, more particularly, your right to privacy and right to access information is essential in the therapeutic relationship. The POPI act, which came into effect in July 2021, has become the benchmark guiding information processing in professional practices.
By signing this document, you acknowledge that your rights in the therapeutic process and the processing of your personal information has been explained. If anything is not clear, you must raise this in your next session to clarify before you sign acknowledgement and consent.
Your rights to confidentiality: Anything shared within the therapeutic relationship will not be shared with any third party without your explicit written consent.
Limits to confidentiality: The law prescribes the following conditions under which a practitioner is obligated to breach confidentially. If it becomes apparent that the client is a risk to themselves or another party. If a child or elderly individual is being placed at risk or in the context of a relationship, either party is at risk due to gender-based violence.
Information collection and storage: Information provided in the session is recorded and stored on an electronic device. The information on this device is backed up to a private iCloud account.
Security measures: All possible efforts have been taken to ensure the protection of your information. All devices that contain personal information require both password and fingerprint ID to be accessed. The information on the iCloud server is subject to Apple’s data security measures. Passwords are changed every three months.
Storage of information: The council requires that all case notes be stored for a minimum of 5 years after the conclusion of the therapeutic relationship. Thereafter the records will be deleted from all devices and all cloud-based servers.
6.Access to information: At any point in the therapeutic relationship, you have a right to review any case notes taken during the process. These notes are reflections on the process and not always statements of fact. To avoid misunderstanding, I reserve the right to provide input when notes are reviewed to mitigate misunderstandings.
Use of information for legal processes: The therapeutic process is a space that requires openness and vulnerability. The threat of litigation is therefore counterproductive to achieving therapeutic goals. As such, I require all clients to agree that anything discussed in therapy or any recorded notes will not be used against their partner as part of a litigation process.
BY SUBMITTING THE FORM BELLOW YOU:
Confirm you have read and understood your rights in the therapeutic process and understand how your personal information will be processed
further consent that Anthony Hawthorn (AnT consulting) has permission to record and process personal information relevant to the treatment goals of the therapeutic process.