Privacy Policy

INFORMATION DISCLOSURE STATEMENT

This document contains important information about the professional services offered by the Registered Counsellor. Please read it carefully. When the client signs this document, it will serve as an agreement that the client fully understands, confirms and consents to the services and assistance provided by the Counsellor.

 

1.         SCOPE OF PRACTICE

 The Counsellor is registered with the Health Professions Council. Being registered under the Health Professions Act, 1976 (Act No. 56 of 1974), gives health care practitioners certain rights and responsibilities. The Counsellor is involved with assessments for the purpose of screening, treatment, referrals, individual, teenage, relationship, group, family, online, telephonic and couples consultations/counselling in order to facilitate psychological interventions and promote mental health.

My approach is from a Solution stance where the focus is on promoting wellness and well-being, where the client is encouraged to draw upon their own internal resilience (strengths and competencies) and to make use of the assets in their life contexts to deal with difficulties and challenges as well as finding solutions to difficulties.

 

2.  COUNSELLORS RESPONSIBILITIES TOWARDS THE CLIENT

• Confidentiality

With the exception of specific events described below, the client has the absolute right to confidentiality regarding counselling and assessments. I cannot and will not tell anyone else what I have been told. The National Health Act (Act No. 61 of 2003) states that all individuals have a right to confidentiality, and this is consistent with the right to privacy in the South African Constitution (Act No. 108 of 1996).  Rule 13 of the Ethical Rules of the HPCSA states that a counsellor may divulge information regarding an individual only if this is done:

• At the instruction of a court;
• With the express consent of the client (above the age of 12 years);
• With the written consent of a parent or guardian of a minor under the age of 12 years;
• Disclosures in the public interest where the individual would be prone to harm themselves or others, as well as reporting acts of abuse against the child to the authorities.

Under the provisions of the Health Act, I may legally speak to another healthcare provider or a member of the child’s family without prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect the client’s privacy even if the client releases me in writing to share information. The client may direct me to share information with whomever they choose, and the client can change his/ her mind and revoke that permission at any time. The client may request anyone to attend a counselling session with them.

If the client is attending family counselling and decides to have some individual sessions as part of the counselling, what is said in those individual sessions will be considered to be a part of the family counselling, and can and likely would be discussed in joint sessions.

• Consent

Children above the age of 12 years have the legal capacity to give consent for counselling in terms of the Children’s Act (Act No.38 of 2005) or the Choice on Termination of Pregnancy Act (Act No. 92 of 1996). Healthcare practitioners should make sure that the client is sufficiently mentally mature to understand the nature and effect of the treatment to which they are consenting.

Counselling is most effective when a trusting relationship exists between the Counsellor and the client. Privacy is especially important in securing and maintaining that trust. One goal of counselling is to promote a stronger and better relationship between children and their parents or between spouses. However, it is often necessary for individuals to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. Therefore children must be given the opportunity to make decisions regarding their mental health and the support they need to address problems. It must be made clear that my role is limited to providing treatment and that the client or parent/guardian will not involve me in any legal dispute, especially a dispute concerning custody or custody arrangements (visitation, etc.). None of our interactions can be used for psych-legal purposes either.

• Record-keeping

It is required in my profession to keep treatment records Every time a client visits any healthcare provider, information is collected about the client and their physical and mental health. It may be information about past, present or future health conditions, or the treatment or other services received or about payment for healthcare. It would include the following information:

• Personal history: childhood, in school and at work, and marital history.
• Reasons for coming for treatment. The client identified problems, complaints, symptoms, needs, goals, and strengths.
• Screenings are the medical terms for the problems and symptoms.
• A treatment plan. These are the treatments and other services which will best address the identified problems.
• Brief progress notes of the discussion in the sessions.
• Information about medications the client has taken or is taking.
• Records received from others who treated or assessed the client.
• Psychological assessment scores, school records, etc.
• Billing and medical aid information.

Under the provisions of the Health Care Act, individuals have the right to a copy of the file at any time, provided I am given the chance to copy it for my own records. However, because these are professional records, they can be misinterpreted by untrained readers. If the client wishes to see the records, I recommend that the client review them in my presence so that we can discuss the contents. The client has the right to request that I correct any errors in the file. The client has the right to request that I make a copy of the file available to any other healthcare provider with a written request. I maintain the records in a secure location that cannot be accessed by anyone else. The information in the assessment reports and counselling notes are only for the client’s or parent’s/guardian’s information and may not be used for any other purposes like psycho-legal or legal action.

After a psychological assessment has been administered the client will be provided with a copy of the results which will be discussed with him/ her and the parents/guardians. However, due to the sensitive nature of psychological counselling and the confidentiality thereof, no written reports will be given to the client or parents/guardians.

 

3.  PRIVACY POLICY

• Social media

This section outlines my office policies related to the use of social media. Please read it to understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the internet changes, there may be times when I need to update this policy. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy.

• Friending

I do not accept friend or contact requests from current or former clients on any social networking sites (Facebook, LinkedIn, Twitter, etc). I believe that adding clients as friends or contacts on these sites can compromise confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship. In addition, viewing online activities without consent and without explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your (child’s) online life that you wish to share with me, please bring them into our sessions where we can view and explore them together during the counselling.

• Interacting

Please do not use SMS (mobile phone text messaging) or messaging on Social Networking sites to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with me in public online if we have an already established client/counsellor relationship. Engaging with me this way could compromise your confidentiality.

If you need to contact me between sessions, the best way to do so is by phone 082 452 7531. Direct email info@corneliapieterse.co.za at is second best for quick, administrative issues such as changing appointment times or on my website info@corneliapieterse.co.za. See the email section below for more information regarding email interactions.

• Use of search engines

It is NOT a regular part of my practice to search for clients on Google or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that the client is in danger and has not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find a client, find someone close to the client, or to check on the client’s recent status updates) becomes necessary as part of ensuring the client’s welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with the client at the next meeting.

 

• Transmission of electronic information (EMAIL/ FAX)

Whenever I transmit information about the client electronically (for example, sending bills or faxing information); it will be done with special safeguards to ensure confidentiality. Please ensure that all information that the client wishes to be faxed is sent to a secure private line. If the client elects to communicate with me by email, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from the client, and any responses that I send to the client, will be printed out and kept in the treatment record.

 

4.  INFORMATION DISCLOSURE POLICY

 Diagnosis

If a third party such as a medical aid is paying for the account, I am required to give a description code to that third party for the settlement of the account. This is called a diagnostic code, diagnostic codes are technical terms that describe the nature of the client’s problems and something about whether they are short-term or long-term problems. If I do use a diagnostic code, I will discuss it with the client. All of the diagnostic codes come from a book titled the DSM-V and a medical code is attached ICD-10. Please take note that the Counsellor does not complete SARS forms for reimbursement reasons due to confidentiality issues.

• Disclosure of information to third parties

The client/ parent/ guardian has the right to provide consent for information to be shared with relevant professionals for the well-being of the client (necessary documentation needs to be completed). Please be aware that where there is a need for a child to receive accommodations (concessions) for tests and exams in a school setting, the sharing of psycho-educational reports regarding the child’s scholastic functioning is a prerequisite. The Department of Education (GDE) or Independent Educational Board (IEB) has a panel of professionals (psychologists, psychiatrists, counsellors etc) that use the reports to make an informed decision regarding the granting of specific accommodations (concessions); however, the confidentiality of the reports cannot be guaranteed by the Counsellor. Furthermore, to assist the child with any remediation and or support he/ she might need in the classroom, the nature of the scholastic functioning of the child could be discussed with the relevant heads of departments and teachers, still ensuring that the child’s privacy is upheld. This is only done in the best interest of the child and only information that is relevant will be discussed by the Counsellor.

 

5. COUNSELLING POLICY

• Therapeutic rights and considerations

 

Counselling is a partnership where both parties have a common goal. The client has the right to ask questions about anything that happens in counselling. I’m always willing to discuss how and why I’ve decided to do what I’m doing and to look at alternatives that might work better. The client can feel free to ask me to try something that the client thinks will be helpful. The client can ask me about my training for working with his/ her concerns and can request that I refer him/her to someone else if the client decides I’m not the right counsellor. The client is free to leave counselling at any time but must discuss the decision with me timeously.

Counselling has potential emotional risks. Approaching feelings or thoughts that the client has tried not to think about for a long time may be painful. Making changes in his/ her beliefs or behaviors can be scary, and sometimes disruptive to the relationships the client already has. The client may find his or her relationship with me to be a source of strong feelings. It is important that the client consider carefully whether these risks are worth the benefits of changing. Most people who take these risks find that counselling is helpful. If the clients are unhappy with what’s happening in counselling, I hope he or she will talk about it with me so that I can respond to their concerns. It must be noted that the success of the outcome of counselling cannot be guaranteed as it depends on the client’s willingness to make decisions and changes. Also, the counselling might not be in line with the client’s expectations about the level of change or timeframe in which change is expected to occur. Therefore, continual discussion about the goals and progress in counselling is essential. The client is responsible for coming to the counselling session at the scheduled time. If the client is late, we will end on time and not run over into the next person’s session.

• Termination of the therapeutic relationship and emergencies

The client normally will be the one who decides counselling will end, with three exceptions. If we have contracted for a specific short-term timeframe, we will finish counselling at the end of that contract. If I am not in my judgment, able to help the client, because of the kind of problem the client has or because my training and skills are in my judgment not appropriate, I will inform the client of this fact and refer the client to another medical professional who may meet his or her needs. If the client exhibits violent behaviour, threatens (verbally or physically) or harasses myself or the office, I reserve the right to terminate the client unilaterally and immediately from treatment. If I terminate the client from counselling, I will offer the client referrals to other sources of care, but cannot guarantee that they will accept the individual for counselling. If the client is experiencing an emergency outside of my regular office hours, support lines like SADAG, Lifeline or Famsa can be contacted. If the client believes that he or she cannot keep themselves safe, please call the emergency services, or go to the nearest hospital emergency room for assistance.

 

6. ASSESSMENT POLICY

Psychological assessments are conducted for a variety of reasons, including screening clarification, qualification for services such as school accommodations, and treatment recommendations. A psychological assessment seeks to provide information about a specific question pertaining to psychological, cognitive or emotional functioning as well as subject and career guidance using standardized and empirically validated tools.

Psychological assessments are intensive and usually consist of an interview, a review of relevant records, testing sessions, a feedback session to go over the results, and the preparation of a written report. It is very important that the client is truthful and provides their best effort during the assessments in order to gain an accurate assessment. The assessments take place within a controlled environment and the client may not take the assessment media or results of that assessment home in any form (electronically/written). A detailed composite of the results with clear explanations will be given to the client in the form of a written report and discussed with them.  There can be no guarantees about the outcome of a psychological assessment. Furthermore, undergoing a psychological assessment may involve discussing unpleasant aspects of the client’s life and may lead to unanticipated results and or conclusions that may be discomforting. The recommendations and suggestions made will only be in the client’s best interest.

 

7.  CONSENT OF MINORS WITH REGARD TO DIVORCED/ SEPARATED PARENTS/ GUARDIANS

Based on the Divorce Act 24 of 1987 as well as the Children’s Act 38 of 2005, when dealing with minor children – written consent from BOTH parents is a pre-requisite. Without consent, I may not continue to assess the client. Assessments will not be done for forensic purposes to be used in a court of law. The release of any report or assessment results to third parties is dependent on the consent of BOTH parents and is strictly governed by the ethical guidelines of the HPCSA. Where there is no means to contact the biological parent, it then is necessary that the referring parent obtains an affidavit from the police indicating this fact, as well as stating that the referring parent can consent to assessments/ counselling in the best interest of the child. The document from a court ruling to this effect can also be submitted.

 

8.   NEGOTIATION AND MEDIATION POLICY

Any claims, disputes, and controversies arising out of or in relation to the performance, interpretation, application, or enforcement of this agreement, including but not limited to breach thereof, the client shall try to resolve the dispute by negotiation. This entails that one party invites the other in writing to a meeting to attempt to resolve the dispute within 7 (seven) days from the date of the written invitation.

If the dispute has not been resolved by such negotiation concerning this agreement, the parties will be referred to mediation before, and as a condition precedent to, the initiation of any legal action or proceeding, including arbitration. Mediation may be initiated by either party writing to the other party or identifying the dispute which is being suggested for mediation. The parties agree to participate in the mediation in good faith and undertake to abide by the terms of any settlement reached.

 

9. CONSENT TO COUNSELLING AND PSYCHOLOGICAL ASSESSMENTS

I have read this document, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understood it. I consent to the use of a diagnostic code in billing, and to the release of that information and other information necessary to complete the billing process. I agree to pay counselling and assessment fees. I understand my rights and responsibilities as a client, and my counsellor’s responsibilities to me. I agree to undertake assessment procedures and/ or counselling with The Counsellor. Signing below indicates that the client has read the information in this document and agrees to abide by its terms during our professional relationship.