Housekeeping

Intake Form: Client Details and Consent

Please download and complete this Intake and Consent Form 2023 then email it to practice@queerpsychologist.co.za.

By signing the Intake Form, you acknowledge that you have understood and agreed to the following:

1. That you have read the Practice Terms and Conditions and have had an opportunity to ask questions on aspects thereof that you were uncertain about.
2. That you are familiar with the Practice Privacy Statement which sets out how your personal information is collected and protected when you engage with me in my practice,
3. To always ask, even after you have left the practice, if you were uncertain about something. If you keep quiet, I will assume that you have understood everything and agreed with any processes, consents, policies and/or forms.

---

Protection and Promotion of Access to Personal Information

I am committed to safeguarding the confidentiality of my clients’ information and to preserving their constitutional right to privacy. In this regard, I am obliged to comply with the Protection of Personal Information Act, 2013 (POPI), the relevant provisions of the Promotion of Access to Information Act, 2000 (PAIA); the National Health Act, 2003; and the Mental Health Care Act, 2002; among others, and the ethical rules of the Health Professions Council of South Africa (HPCSA). For more information, see Practice PAIA:POPI Manual. If required, here are copies of request and objection forms as per the POPI and PAIA legislature:

POPI Form 1: Objection to the processing of personal information

POPI Form 2: Request for correction, deletion or destruction of personal information or records

PAIA Form C: Request for access to record of private body

Out-of-Pocket Rates from 1 March 2024