In knowledge and appreciation of the benefits and risks as made known to me by Lara-Mari van der Walt, and as reflected in this form, I hereby give consent to participate in the counselling. I further acknowledged that informed consent must be obtained from me before changing or altering the nature of the intervention of counselling provided to me.
Confidentiality and Limits on Confidentiality
I have been advised by Lara-Mari van der Walt that all communications with me and all records relating to the provision of services to me are confidential and may not be disclosed without my written consent. I have also been advised that the law places certain limits on the confidential nature of the counselling provided to me. I have been advised that typically these limits on confidentiality may arise if the professional perceives that there is a risk of harm in situations such as the following:
• If I present an imminent danger to myself or others the law requires that steps be taken to prevent such harm;
• If a child is in need of protection a report must be filed with the appropriate agency or authority;
• If a vulnerable adult is abused or neglected a report may be filed with the appropriate government agency;
• If a court orders the disclosure of records.
Please note that written reports are only sent to official institutions. These reports are not suitable for court cases or appearances.
I understand that I have the right to confidentiality with respect to all communications with me and all records relating to the provision of counselling to me.
Acknowledgement and Consent
1. I am voluntarily making use of these services. I am aware that I have the right to end these services at any time.
2. I have been fully informed of the costs involved for the services and that I will be held accountable for payment of services rendered.
Tariffs and payment
1. The account must be paid in full to reserve a consultation.
2. The person responsible for the account shall be liable for the settling of this account.
3. Appointments cancelled more than 24 hours in advance will not be refunded but will be available as credit to use for any BraveBraaf services.
4. Appointments not cancelled at least 24 hours in advance will be charged at half-price. If you do not keep your appointment or arrive unacceptably late, you will be charged for the full amount.
5. By signing this document, you acknowledge that you have read the information above, clarified any uncertainties and that you consider yourself bound to the contents thereof.
I, the Client/Parent/Legal Guardian, acknowledge that I have had the opportunity to carefully read this document to ask, and have answered, any questions or concerns I have about it or arising from it.
I further acknowledge that I have read and understood the information contained in this document.
Permission to process personal information
For the purpose of this Agreement, the terms personal information, data subject, processing, responsible party and operator are defined as set out in the Protection of Personal Information Act (POPIA).
I, the Client/Parent/Legal Guardian, the duly appointed representative of the Client, hereby agree that Lara-Mari van der Walt may process all personal information related to the company for lawful business reasons, operations and activities of Lara-Mari van der Walt. Types of information will depend on the purpose of the data collection, and will only be processed for the intended purpose.
Wherever possible, all personal information will be processed by Lara-Mari van der Walt (as the responsible party). However, the company further agrees that Lara-Mari van der Walt may contract with other organisations to provide support services as suppliers to Lara-Mari van der Walt, and in the course of their work, may process personal information of the company. Lara-Mari van der Walt will legally bind all service providers to its privacy policy in their access and processing of any personal information of the company.
Purpose of the processing of personal information:
We would like to clarify how, and for which purpose we will be processing your personal
information. We mainly collect, store, use and make available your personal information in order to give you access to the services and products of Lara-Mari van der Walt.
We will only process your information for a purpose that you reasonably would expect, including the following:
• To provide you with advice, products and services that you have requested;
• To verify your identity and to confirm credit referrals;
• To organise, administer and manage logistical functions;
• To notify you of new products or developments that may be of interest to you;
• To verify or update your personal details;
• To receive payment from you for goods or services rendered;
• To act in the lawful interest of Lara-Mari van der Walt;
• To meet any legal or legislative duties imposed upon Lara-Mari van der Walt.
You have the following rights:
• The right to know what personal information we store, how such information is processed, and under which conditions Lara-Mari van der Walt make such information available.
• The right to correct or update your personal information.
• The right to withdraw this permission related to your personal information.
Should you believe that your personal information is not being processed correctly, or that
your personal information is used for a purpose not originally intended, please contact our
Information Officer:
INFORMATION OFFICER: Lara-Mari van der Walt
E-MAIL: admin@bravebraaf.co.za