Informed Consent & Privacy (POPIA) Notice To be completed by the person to be assessed, or by their authorised representative

Informed Consent

1. I, the undersigned, , give my informed consent to undergo psychological and/or neuropsychological assessment, diagnosis, and intervention — whether as the client myself, or as the authorised representative of the direct recipient of these services by the Psychologist. It is my responsibility to provide the Psychologist with the most accurate information regarding my background and medical condition, or that of the direct recipient of these services.
2. I am aware that there are legal limits to the confidentiality of information relating to me and/or the direct recipient of the services. Specifically, I grant the Psychologist permission to disclose summarised information relating to my (and/or the direct recipient's) condition to the person/s involved in treatment, whether in writing, telephonically, or by email or any other secure method.
3. I also consent to my data being used for research purposes. I acknowledge that, should this occur, my personal details will not be disclosed and the data will be de-identified.
4. I understand that, where the referral is for a clinical neuropsychological assessment, this is generally for diagnostic, therapeutic, or clinical purposes and not for medico-legal purposes. Any report generated following such an assessment will therefore be a summary of the key findings, intended for treatment, monitoring, or diagnostic purposes only.
5. Feedback to the client is normally provided orally (telephonically, via Zoom, or in person) and is billed separately. Please be aware that clinical summaries of findings are charged separately and are usually not claimable from medical aids; these are therefore for the client's account. Please also note that any reports required for non-clinical purposes — for example, occupational, insurance, or medico-legal purposes — are charged differently, based on the additional requirements involved.

Personal Details of Client

Privacy Notification: Processing of Personal Information

1. I am required to collect and process the personal information set out above, together with any other relevant personal information about you — including but not limited to session records, notes, and correspondence — in order to provide psychotherapy and neuropsychology services, in accordance with HPCSA regulations and the Protection of Personal Information Act No. 4 of 2013 (POPIA).
2. This information will be used only for the purposes for which it was collected (the provision of psychotherapeutic services and/or neuropsychological assessment). Please note that these services may not be possible if you do not provide this information, or if you fail to inform me of any changes or updates. This practice may record sessions for note-taking purposes only; transcripts are not retained, while process notes are kept solely for reflection and therapeutic purposes. All such notes are confidential.
3. This practice may use Artificial Intelligence (AI)-based tools in limited ways to support psychological assessment, note-keeping, administrative tasks, or peer-reviewed clinical research that aligns with the ethical and legal guidelines issued by the HPCSA and POPIA. This includes computer-based tools to assist with data collection (record-keeping), summarising information, or automating certain tasks — but not for diagnosis, therapy, or decision-making. Where AI tools are used, they are used for drafting and are clinician-reviewed. It is important to note that decisions and interpretations are always finalised by the attending Clinical Neuropsychologist.
4. Your information will be stored securely in physical and/or electronic form, and I will review security safeguards on an ongoing basis to ensure that your information is kept safe and confidential.
5. I may disclose your information to service providers who are involved in, or who enable, the delivery of services to you — such as medical schemes or other healthcare professionals. In such cases, this will be as per your explicit permission (e.g. based on the referral from the service provider or as per your instruction). This may include the results from assessments, or the sharing of information, for the purposes of care and treatment. This may also include the processing and sharing of information for the purpose of collecting outstanding fees. These third parties include email and messaging service providers (for example, Gmail or Outlook) and cloud storage providers (for example, Dropbox and/or OneDrive), who may be located outside of South Africa. When needed, appropriate password protection will be applied to secure your information on these platforms, and I will take all reasonable steps to ensure that the privacy protections of such third parties comply with the conditions of POPIA.
6. You have the right to request that I update, correct, or delete your personal information using the relevant forms set out in POPIA (Form 1 and Form 2), which can be requested directly from me. In accordance with the Promotion of Access to Information Act (PAIA), and the processes set out in this practice's PAIA manual, you also have the right to request a copy of the personal information I hold about you; the copying and provision of which may be subject to a legally permissible fee. The PAIA manual and Form C (request for information) can be requested directly from me.
7. Disposal of information. In accordance with HPCSA rules, all documentation will be kept for a minimum of six years, after which the records will be destroyed unless you expressly request otherwise. In the case of minors, records will be kept until the age of 21 years, or for a minimum of six years from the date of assessment, whichever is longer. In medico-legal cases, information will be kept for a minimum of two years after settlement of the matter, unless otherwise requested. Paper records will be destroyed by shredding, and electronic records will be deleted. Where cases are used for research or further education, the information will be de-identified.
8. Responsibility for compliance with POPIA and PAIA lies with the registered Information Officer for this practice, Ms Urvashi Maganlal.