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Booking your first appointment
 
Step 1  Call Vanessa on 021 782 0593 to secure an available slot
Step 2  Review the document on informed consent
Step 3  Fill in your particulars and submit.
Step 4 The physical address

 

Informed Consent for Therapeutic Consultation 

 

 

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. 

 

The council requires me to keep notes that may contain 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 clicking the submit button, you acknowledge that your rights in the therapeutic process and the processing of your personal information have been explained. Furthermore you confirm that you have given consent to the details as they have been explained to you. If anything is not clear, you must raise this in your next session to clarify before you sign the acknowledgement and consent. 

 

  1. Your rights to confidentiality: Anything shared within the therapeutic relationship will not be shared with any third party without your explicit written consent. 

  2. Limits to confidentiality: I understand that there are both mandatory and permissive exceptions to confidentiality, namely if I present an imminent danger to myself or others. By law it is required that steps be taken to prevent such harm. Furthermore if a child or elderly individual is being placed at risk the law may also require that certain mandatory steps be taken that might necessitate the breaking of confidentiality. 

  3. 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. 

  4. 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.

  5. 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. No clinical notes may be duplicated or removed from the premises. 

  7. 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 in any litigation process.

  8. Cancellation or missed appointments: Please note that any appointment that is not cancelled within 24 hours will be billed at the full rate.      

 

 

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

 

and

 

further consent that Anthony Hawthorn (AnT consulting) has permission to record and process personal information relevant to the treatment goals of the therapeutic process.  

Particulars 
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Name, Surname and DOB of chidren.

Please provide a brief discription for why you are seeking counseling services at this time.

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