Register - The Psychology Couch

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Client Registration

Physical Address: Homestead Park - 37 Homestead Lane
Corner 12^th Avenue, Rivonia, Sandton
2191
Office Phone Number: 011 234 0741
Mobile Phone Number: 071 682 7107
Web: www.thepsychologycouch.com
Email: admin@thepsychologycouch.com

All details are Strictly Confidential

Client Details

Your Name(*)

Please let us know your name.

Physical Address(*)

Please let us know Physical Address.

Your Surname(*)

Please let us know your Surname

Postal Address(*)

Please let us know your Postal Address.

Contact Details

Cell Number(*)

Please Let us Know your Cel Phone Number.

Your Email(*)

Please let us know your email address.

Work Number(*)

Please Let us Know your Work Phone Number.

Date of Birth(*)

Please tell us your Date of Birth

Name of Referring Doctor - Health Care Practitioner - Person - Website(*)

Please tell us who was your Referring Doctor - Health Care Practitioner - Person - Website: who told you about us. Type self if none did

Home Number(*)

Please Let us Know your Home Phone Number.

ID Number or Passport Number(*)

Please supply your ID Number

Fax Number

Please Let us Know your Fax Phone Number.

Alternative Contact Person in Case of an Emergency

No.1 Full Contact Person Name(*)

Please let us know your No.1 Contact Person Full Name.

No.1 Relationship(*)

Please tell us your No.1 Person Relationship to you eg. Father, Mother, Uncle, Aunt, Friend etc.

No.1 Contacts Phone Number(*)

Please Let us Know your No.1 Contacts Phone Number.

No.2 Full Contact Person Name

Please let us know your No.2 Contact Person Full Name.

No.2 Relationship(*)

Please tell us your No.2 Person Relationship to you eg. Father, Mother, Uncle, Aunt, Friend etc.

No.2 Contacts Phone Number

Please Let us Know your No.2 Contacts Phone Number.

Physical Address: 40 River Road
Rivonia
2191
Office Phone Number: 011 234 0741
Mobile Phone Number: 071 682 7107
Web: www.thepsychologycouch.com
Email: admin@thepsychologycouch.com

Person Responsible for Account

First Name(*)

Please let us know the First Name of Person responsible for account.

Residential Address(*)

Please let us the Residential Address of the Person Responsible for the Account.

Residential Code.(*)

Please tell us the Residential Code of the Person Responsible for the Account.

Surname(*)

Please let us know Surname of Person responsible for account

Postal Address.(*)

Please let us know the Postal Address of the Person Responsible for the Account.

Postal Code.(*)

Please tell us the Postal Code of the Person Responsible for the Account.

Contact Details of Person responsible for account

Cell Phone Number(*)

Please Let us Know the Cel Phone Number of Person responsible for account.

Email Address(*)

Please let us know the email address of the Person Responsible for the Account.

Work Phone Number(*)

Please Let us Know the Work Phone Number of Person responsible for account.

Date of Birth(*)

Please tell us the Date of Birth of the Person Responsible for the Account.

Home Phone Number(*)

Please Let us Know the Home Phone Number of Person responsible for account

ID Number or Passport Number(*)

Please supply the ID Number of the Person Responsible for the Account.

Fax Number.

Please Let us Know the Fax Phone Number of Person responsible for account.

Medical Aid Details

Medical Aid Name(*)

Please Let us Know your Medical Aid Name.

Main Member.(*)

Please Let us Know Who is the Medical Aid Main Member.

Main Member ID Number.(*)

Please Let us Know the Medical Aid Main Member ID Number.

Medical Aid Plan.(*)

Please let us know your Medical Aid Plan

Membership Number.(*)

Please Let us Know your Medical Aid Membership Number.

Dependent Code

Please Let us Know the Medical Aid Dependent Code.

Physical Address: 40 River Road
Rivonia
2191
Office Phone Number: 011 234 0741
Mobile Phone Number: 071 682 7107
Web: www.thepsychologycouch.com
Email: admin@thepsychologycouch.com

Terms and Conditions

Please take Note of the Following:

Unless otherwise arranged, fees are claimed directly from the medical aid. However if the medical aid does not settle the account in full, the Patient will be liable for the outstanding amount.
Medical aids require an international Statistical Classification of Disease and Health Problems Code (ICD 10 Code). Please note that this code is required to be given on your statements for your medical aid. Please be aware that certain future policies may require your medical aid to give them access to the diagnosis of this treatment. Please feel free to discuss any questions you have about the ICD codes.
Due to the nature of Akeso multidisciplinary therapeutic approach, relevant information regarding treatment will be shared with your treating psychiatrist.
You filling out the form indicates that:
1. I will only make contact with persons you have advised me that I can contact.
2. The Limits of confidentiality have been discussed with you.
3. I understand that I am fully responsible for settlement in full of all fees / shortfalls due to this practice and undertake to ensure their payment.
4. Should I fail to make payment within 3 (three) months, I am fully aware that legal procedure will be taken against me, and that my debt will be handed over to either lawyers or debt collecting agencies. You will also incur all extra cost.

Username(*)

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Verify E-mail(*)

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Password(*)

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Verify Password(*)

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By Ticking this Box(*)

I Accept and declare that I have understood and agree to this contract.

Please tick the box to accept and submit form.

Head Office

37 Homestead Road,
Corner 12th Avenue
Block F, Homestead Park
Rivonia, Sandton
060 961 7882
Tel: (011) 234 0741

Online consultations are now available

Please note that if you are unable to contact us on 011 234 0741 due to the Load shedding, kindly contact us on 060 961 7882