Consent for Therapy

Title

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Male Female

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Date of Birth

Age

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Single Married Divorced Widowed

Physical Address

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Home Tel

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Referral

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Medical Aid

Medical Aid Plan / Option

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Next of Kin: Name

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General Practitioner

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Psychiatrist

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Informed Consent

Different methods of therapeutic intervention used by Dr Lize.
Hypnotherapy - Ego State Therapy (EST)
Ego State Therapy (EST) is a psychotherapy that views the human personality as being composed of a number of parts, or sub-selves, that constitute something like an internal family. It was developed by John and Helen Watkins as a form of hypno-analysis and is mostly conducted when patients are in formal trance. It is a highly effective treatment modality. One of the advantages of EST is that it can deal with deep unconscious structure. It also has the capacity to produce deep changes in personality structure in a relatively short period of time.

Hypnotherapy - Medical Hypno-analysis
Medical Hypno-analysis has as a basic premise that a symptom represents the survival response of the subconscious mind to a perceived threat. Analysis is done in formal trance to identify the perceived threats which have become frozen in the subconscious mind. When the subconscious mind, which is compelled to ensure our survival, realizes that these threats no longer exist, it can let go of the symptom or survival response.

Brain Working Recursive Therapy ( BWRT)
BWRT - created by Terence Watts in 2011- is an innovative and exciting new therapy, creating long-lasting results. It presents a new view of the subconscious mind- one that is very “user-friendly” and easy for the client to understand. It is a new model of psychology and psychopathology that fits comfortably with current neuroscientific thinking. BWRT is solution-focused and evidence-based, and extremely effective. Change is brought about in the minimum amount of sessions, compared to other therapeutic systems. It operates on the principle that our brains respond to events and make decisions even before we are physically aware of them. The brain is however adaptable and capable of learning in a fast and efficient way. No unnecessary questions are asked, no time is wasted. The focus is on changing neurology with neuroscience. The methodology is quick, painless and highly effective.

Eye Movement Integration (EMI)
EMI is a brief therapy technique involving the use of eye movements in the treatment of trauma. It is amazingly rapid in its effects, freeing clients from the burden of unresolved memories of almost any form of trauma. EMI provides a method to facilitate access to the client’s traumatic memories, incorporating all the fragmentary recollections of the trauma into an integrated whole. This enables the client to place the trauma into perspective as part of his/her personal history, and not as an ongoing source of distress in the present.

Brain spotting
Brain spotting as developed by David Grand, is closely related to the EMI in the sense that it also uses the field of vision to access traumatic memories. It is hypothesized that points in the visual field correspond to parts of the brain. Brain spotting is a tool used to neurobiologically locate, focus, process and release experiences and symptoms which are typically out of reach of the conscious mind and its capacity for language and recognition.

Somatic Experiencing (SE)
Somatic Experiencing was developed by Peter Levine and can be described as a highly effective psycho-biological method for resolving trauma symptoms and relieving chronic stress. Not only does SE provide a framework to assess where a person is stuck in the fight, flight, freeze or collapse responses to trauma, but also provides tools to resolve these fixated psychological states.

Mindfulness
I assist my client’s in the development of mindfulness. I use Rob Nairn’s definition of mindfulness: “Mindfulness can be defined as knowing what is happening while it is happening, no matter what it is.” Mindfulness is a deep broadening of the mind that increases sensitivity and perceptiveness. It increases one’s self-awareness, which is the capacity to first see and know and understand what is going on inside one’s own mind, and then to know what is going on around oneself. Through the development of mindfulness the ground for profound inner growth is prepared, and we experience deeper states of consciousness. We learn how to be in the moment, which is after all where life itself happens.

I hereby grant Dr Lize full permission, during the course of the therapeutic process to utilize any combination of these methods of therapy which she deems suitable., with the understanding that Dr Lize undertakes to explain these methods to me prior to utilizing them. I do accept however that the onus to ensure that all my questions have been satisfactorily answered during this discussion, rests on me.

Confidentiality and Limits on Confidentiality
I am fully aware that all communications with me and all records relating to the provision of psychological services to me are confidential and may not be disclosed without my written consent. I am also aware that the law places certain limits on the confidential nature of the psychological service provided to me. I have been advised that typically these limits on confidentiality may arise if Dr Lize perceives that there is a risk of harm in situations such as the following:

i. Should I present an imminent danger to myself or others, the law requires steps to be taken to prevent such harm.

ii. Should a child be in need of protection, a report has to be filed with the appropriate agency or authority.

iii. Should a vulnerable adult be abused or neglected, a report may be filed with the appropriate government agency.

There is also a limit on confidentiality should the court order the disclosure of records.

Confidentiality is also applicable to children under the age of 18. Dr Lize shall regularly inform parents or guardians about the therapeutic process and the progress of the client. As a general rule, no information will be given to a parent or guardian about the content of a session without the relevant client’s consent. Dr Lize does however reserve the right to inform a parent or guardian if it appears that the relevant child makes him- or herself guilty of criminal behaviour, or threatens with, or is involved in behaviour which is considered to be dangerous or potentially dangerous.

Payment
In the case of medical aid payments, the practice of Dr Lize will submit accounts to the patient’s medical aid. However, where the medical aid fails to settle the account, the patient and the undersigned will be held liable for the payment of the account.

Being Courteous
I agree to being courteous by informing Dr Lize as soon as possible should I need to cancel my scheduled appointment with her.

Acknowledgment and Consent

I hereby acknowledge that I have had the opportunity to carefully read this document, and to have asked and have had answered, any questions or concerns I have about it or arising from it. I further acknowledge that I have read and understood the information contained in this document.

Full name of Patient/Parent/Legal Guardian

I am the

Patient Parent of the Patient Legal Guardian of the Patient

Signed

Date

Signed - Person responsible for payment

Date

POPIA

“We shall process (collect, use, store and eventually delete or destroy) your personal information as per the Protection of Personal Information Act, No 4 of 2013 (as amended) (“POPIA”). By completing this form, you accept and agree that we may process, further process and share your personal information with our affiliates, partners or staff in order to render the services.”