Intake & consent form for Adult ADHD assessment

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Please note that payment is accepted via EFT (SA bank only) or secure credit/debit card portal (international banks) only. A link will be sent to you prior to your assessment if requested.
Please indicate whether you will paying via
If credit/debit card is selected, a link will be sent to you prior to your assessment.

Medical aid details

Should you not have medical aid or choose to not use it then you can simply type NA (Not applicable) in the medical aid info boxes below.
Principal member name:

Details of person responsible for account

Please note that a copy of the confirmation will be sent to the person responsible for payment
Name

Details of patient:

Name of patient:

Medical History (Please complete this as accurately as possible)

Have social skills and interpersonal relationships been a challenge for you? This can be elaborated on during the assessment.
This person will be sent a questionaire in which to complete.

Payment instructions

Please note that Dayne Williams and associates operates as a cash practice and therefore the patient is responsible for payment. Once payment has been made you will be issued with a receipt which can be used to claim back from medical aid. Please consult your medical aid first to ensure funds are available for psychological sessions.
Payment must be made on or before the day of assessment with a POP sent to accounts@daynewilliams.co.za. No assessments can commence without this. Please find banking details below if paying from a South African bank account. If you are paying from an international account then a payment link will be sent to you.
Bank Details
Account Holder: D Williams & Associates
Bank Name: FNB
Branch Number: 050655
Account Number: 63117157156
SWIFT Address: FIRNZAJJ
Please use name and surname as a reference

Consent form

I hereby give permission for Dayne Williams and/or Robyn Gordon to interview, assess and provide treatment in accordance with the guidelines and terms mentioned below:
1. Confidentiality and Privacy: I acknowledge that all private information shared in the therapeutic process will be treated as highly confidential. No information will be disclosed without my explicit consent unless required by a Court of Law. While every precaution is taken to ensure the security of electronic communications, I acknowledge that online platforms may pose inherent risks to privacy and confidentiality.
2. Informed Consent: I confirm that I am providing this consent willingly, without undue influence from any party.
3. Communication Platforms: I consent to the transmission of information and reports (where applicable) via email, Google Meet, and/or WhatsApp. I understand that these platforms will be used to share relevant information with me or other specified medical practitioners as necessary. I acknowledge that despite efforts to secure all digital platforms, electronic transmission of information can carry some privacy risks, including potential breaches beyond the practitioner’s control.
4. Online and International Therapy Limitations: Due to the online nature of the service, I understand that therapy provided by Dayne Williams operates under South African law and ethical guidelines. While this service is delivered internationally, it may not meet all jurisdictional requirements of my location. I acknowledge that any findings, assessments, or recommendations are based solely on the available information within the online setting, which may limit access to certain in-person cues and observations. As such, these findings are best viewed as provisional. In some instances, in-person services may be recommended in my location to complement the online therapy process.
5. Invoices and Payments: I consent to the communication of invoices to the designated person indicated above and confirm that I am aware of the payment terms as outlined in the confirmation email. Should the practitioner need to submit claims directly to my medical aid, I grant permission for this process.
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