Intake & consent form for Adult ADHD assessment

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 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.

Details of person responsible for account

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

Details of patient:

Medical History (Please complete this as accurately as possible)

This person will be sent a questionaire in which to complete.

Payment instructions

Please note that Dayne Williams 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: Dayne Williams
Bank Name: Capitec Business
Branch Number: 450109 (Branch name - Cape Town)
Account Number: 1050874374
SWIFT Address: CABLZAJJ
Please use name and surname as a reference

Consent form

I hereby give permission for Dayne Williams to interview, assess and provide treatment in accordance with the guidelines and terms mentioned below:
2. Acknowledge that all private information collected about you will be treated as highly confidential; no information will be disclosed without your consent, unless required to do so by the Court of Law.
3. Acknowledge that I/we gave my/our consent, willingly and without being unduly influenced to do so by any person.
4. Give consent to communicate information and reports (where applicable) via email and/or Whatsapp messaging platform to you and/or other medical practitioners.
5. Acknowledge that invoices will be communicated to the person indicated above and that the payment conditions (as outlined in the confirmation email) have been noted. Should the practitioner need to submit direct to medical aid for whatever reason, then this is accepted by the patient.
Please use mouse (pc) or finger (phone/tablet) to sign above