Intake & consent form for Adult ADHD assessment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Assessment fee (£215/€250) Please select the type of payment below *EFT from South African bankEFT from international bankCredit or Debit cardPlease 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 viaEFT (South African bank account)Credit/Debit card (international bank account)If credit/debit card is selected, a link will be sent to you prior to your assessment.Medical aid detailsShould 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: *FirstLastMedical aid scheme:Membership number:Dependent code: (necessary if the patient is not the main medical aid member)Benefit option: (eg. coastal saver) *Referring doctor (if applicable)Details of person responsible for account Please note that a copy of the confirmation will be sent to the person responsible for paymentName *FirstLastEmail *Contact number: *Details of patient:Name of patient: *FirstLastDate of birth: *Contact number: *Medical History (Please complete this as accurately as possible)Please detail any history (if applicable) of ADHD in your immediate family (parents/siblings etc) *Please indicate your birth weight *Please indicate whether your mother consumed alcohol or nicotine during preganacy *Alcohol onlyNicotine onlyBoth nicotine and AlcoholNeitherPlease elaborate (if any) on language related learning barriers experienced during primary/high school *Have social skills and interpersonal relationships been a challenge for you? This can be elaborated on during the assessment. *Very often (very frequently)Often (or quite a bit)OccasionallyNever (or seldom happened)Please indicate if you have been treated for any of the following: *Learning barriers (e.g dyslexia)Obsessive Compuslive DisorderDepressionBipolar DisorderAnxietySleep ApneaSeizure disorders (e.g Epilepsy)NonePlease indicate if you have experienced any traumatic brain injuries during your lifetime *NoYesAt what age did you first experience symptoms? *What has led to you choosing the present moment to assess for possible ADHD? *Please provide the name and email address of a person with whom you currently live that I can contact regarding your assessment. Should you currently live alone, please provide the name and email address of a family member with whom you have lived in the past. Please note this is an important step and must be someone who can speak to the symptoms you have shown. *This person will be sent a questionaire in which to complete. (optional) Please feel free to share any additional information you feel is relevant to your assessment *Payment instructionsPlease 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 & AssociatesBank Name: FNBBranch Number: 050655Account Number: 63117157156 SWIFT Address: FIRNZAJJPlease use name and surname as a referenceConsent formI 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.By signing this form, I acknowledge the terms and conditions of this consent, accepting the potential limitations of online and international therapy services. *Clear SignaturePlease use mouse (pc) or finger (phone/tablet) to sign aboveDate *Submit