Mosima Marole Clinical Psychologist
PR: 0631477 | PS: 0128295
Registration no: 2017/157053/07
RAF vendor no: 6056481
Cell: 073 341 1236 │ Tel: 012 404 5079
Email: admin@maroletherapists.co.za
655 5th Avenue
Les Marais
Gezina
Pretoria
0084

CONSENT FORM ONLINE THERAPY

PLEASE READ THROUGH THIS PAGE AND SIGN IT AT THE BOTTOM

Thank you for your interest in engaging with online therapy. Online therapy involves the use of electronic communications to enable Mosima Marole, Clinical Psychologist to connect with individuals using interactive video and audio communications. Online therapy includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data. The following sheet provides information about online therapy, which will allow you to decide whether you want to consent to psychotherapy using this medium. Please feel free to ask any questions if you need clarification.

Benefits and limitations
Online therapy is a convenient alternative to traditional face-to-face therapy and has been shown to be effective in helping with many difficulties. However online therapy has limitations. There is a lack of “personal” face-to-face interaction which can make therapy less of a relational experience. It is also not an appropriate medium if you are seriously depressed, have serious substance dependence, or you are experiencing intense suicidal or homicidal thoughts. Seeing a mental health professional face-to-face is recommended in these situations. Like most forms of psychotherapy, online therapy can make you feel worse before you start feeling better and the changes you experience may create conflict in your close relationships.

Technological requirements and competences
To engage in online therapy, you will require a device that can connect to the internet and be able to install and use the software that we agree to use for communication. A reliable high-speed internet connection (minimum 4Mbps for video) is also required. Please be aware that online therapy may utilise significant amounts of data, especially if video (300-800MB/hour) is used.

Procedures for technical difficulties
Disruptions can occur when using the internet to communicate. Should our communication be disrupted, I will immediately attempt to reconnect and resume the session. However, if I am repeatedly unable to reconnect for 10 minutes, I will reach out telephonically or the session will be rescheduled (via email) to a later date once connectivity is resumed.

Confidentiality
Any information provided to me will remain confidential and will not be given to a third party unless you give me specific permission to release the information. However please be aware that if there is a significant risk of you seriously harming yourself or another person, I am obliged to act to prevent harm, which may involve giving information to a third party.
Online therapy utilizes the Internet for the transmission of personal information and therefore there are increased risks to confidentiality and it cannot be guaranteed. To protect your confidentiality, I will require that we use services that provide encryption to communicate. Please consider password protecting the devices you use and installing antivirus software to prevent access by third parties.
Please ensure that you use a private space when engaging in online therapy so that intrusions can be minimised.
You consent that your identifying information be shared with third party for billing purposes should you be using a medical aid.

Crisis management
It can be difficult to deal with emergency crisis situations when using online therapy as we are often in separate locations. I will therefore ask you to provide the contact details of a local family member/friend as well as a local medical practitioner who can be contacted in the case of an emergency. If you are in crisis or in an emergency situation and there is a disruption while we are engaging in online therapy, then you should immediately seek help from a family member or go to the nearest hospital.

Legal recourse
I am registered as a Clinical Psychologist (Registration No: PS0128295) with the Health Professions Council of South Africa (HPCSA) and my professional behaviour is governed by this regulatory body. Please note that if you are not located in South Africa then any legal recourse will only be available in South Africa. You can verify my registration with the HPCSA at the following link: http://isystems.hpcsa.co.za/iregister/

Fees
My services are billed by time, as in the case of face-to-face therapy, and sessions are normally 51-60 minutes in duration. My fee is R1 000.00 cash or if you are using a medical aid the funds will be billed to the medical aid. It is still your responsibility to make sure that the fee is paid up should the medical aid not pay. Please be aware that sessions missed or cancelled with less than 24 hours’ notice will be billed. It is important to note that medical aid companies do not provide reimbursement for cancelled or unattended sessions.

    Consent

    I have read the above and understand the risks associated with engaging in online therapy. I agree to participate in online therapy and comply with the policies outlined above.

    I confirm that the following identifying details are correct:

    Name:

    Surname:

    Email:

    Date of Birth:

    I agree that in the case of an emergency where there is a threat of harm that the following persons can be contacted:

    Family/Friend Name:
    Contact Number:
    Medical Practitioner:
    Contact Number:

    Client Signature:

    Date:

    Place: