Sign Up Form

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  • CLIENT SECTION

  • Name *
    First
    Last
     
  • Telephone numbers: (landline and/or mobile): *
    (###)
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  • (###)
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  • City in which you live: *
  • Email address: *
  • Communication *
    I receive an email response to every email I send you (remembering I
    will do my best to do this within a 24 hour period. A single session
    includes client email and psychologist’s response). R100 per session.
    Exchange up to 6 emails per week. R500 per week. Please allow 24 hrs for psychologist’s replies.
    I would like us to communicate in the following way (please tick the option you prefer – you can always change it later)

  • The following information is optional.

  • Name of GP
    First
    Last
     
    (only contacted with your prior knowledge)
  • Tel. No. of Surgery
    (###)
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    ###
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    (please include full dialling code)

  • Date of commencement of this Agreement

    I have read through and agree with all the pages of this Agreement.

    I confirm that I have read the exclusions / conditions where online therapy is not suitable (see “What is Email Counselling”).

    I
    acknowledge that I am ultimately responsible for my own actions. Any
    decisions or actions taken that I feel are a result of online
    counselling, remain solely my responsibility.

  • I agree to the above *
    I agree
  • Signature *
    First
    Last
     
  • Date *
    MM
    /
    DD
    /
    YYYY
     
  •