The Therapy Agreement


Welcome to my practice. I am aware of how significant deciding to work with a therapist can be and you can be proud that you are making a change in your life. You will be in a process of change throughout our time together, and you will most likely make changes in your life after we finish our work together. I hold postgraduate qualifications in clinical psychology and am licensed to practice independently as a clinical psychologist through the Health Professions Council of South Africa (HPCSA). I have worked as a counsellor and as a therapist in a variety of settings. I am committed to my own ongoing professional development and I continually seek to develop my skills in various psychotherapeutic modalities, including trauma resolution, psychodynamic work and group psychotherapy. I practice from home and aim to create an environment of safety and comfort so that healing and growth can take place.

This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.


Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods I use to deal with the areas that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have a great deal of benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there is no way to predict what you will experience.


Our first few (2-4) sessions will involve an evaluation of your needs. In order to do this effectively I may need access to your medical and mental health treatment records. Your signature below will indicate your authorisation to the disclosure and/or use of these records to and by me. You are not obliged to provide this consent and may revoke it at any time, in writing. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If psychotherapy is begun, we will usually schedule one session (one appointment hour of approximately 50 minutes duration) per week at a time that we agree on, however some therapies require more frequent sessions. Consultation times do need to be adhered to and late or early arrivals are not accommodated for through extending the session time or by starting early.

While you are free to end therapy at anytime that you become ready, it is important that you discuss openly with me your desire to end therapy as soon as you begin thinking about that possibility. A planed termination period is always valuable and essential to acknowledge and summarise what you have accomplished, discuss any of the unfinished concerns that you may have and allow for you to grow out of the actual experience of ending. Similarly, if at any point you decide that I am not the right therapist for you, I encourage you to raise this with me and I will gladly help you to find another suitable therapist if we are unable to resolve the concern.


My fees are mindful of the recommended rates on the National Reference Price List (Board of Healthcare Funders) which are adjusted in the January of each year. I am however willing to see some clients based on their ability to pay, if I can be of service to them and they cannot afford my full fee. Fees will be set at the beginning of treatment, and I trust you will negotiate fairly, and that if your circumstances change, you will review your fee with me.

Payment schedules for other professional services will be agreed to when and if they are requested. If you become involved in legal proceedings that require my participation, you will be expected to pay a forensic related fee for my professional time even if I am called to testify by another party.


Please be aware that I invoice, in full, for all booked appointments. I do make provision for two no charge cancellations in any six month period (excluding my cancellations), provided that you cancel 24 hours in advance. This will apply regardless of the circumstances of the cancellation. Justified cancellations of course need to happen for all of us. But consider that when you begin to see me on a regular basis, your regularly time has been scheduled only for you, and cannot be filled by someone else if you cancel. Also, psychotherapy works through the relationship and so consistency and deepening are important. In the case of those cancellations made either by me or by you 24 hours before the booked appointment, I will make all reasonable attempts to accommodate you at another time.


Fees for the first four consultations are payable immediately. Thereafter accounts are due on presentation of the invoice/statement at the end of each month. The subsequent invoice/statement will reflect this payment. I do not bill medical aid schemes directly and you are responsible for settling your account with me directly and then claiming from your medical aid. Most medical aids will usually provide some limited coverage for mental health treatment but few will pay for missed sessions. I encourage you to contact your medical aid in advance and establish what benefits you have available so that we might plan our time appropriately. The Council for Medical Schemes has determined that all healthcare providers are required to include a diagnostic code (ICD-10) on all claims to medical aid for services rendered. I include an ICD-10 code on all my invoices and hence you should protect your invoices and you should not claim from your medical aid if you wish for this information to remain confidential.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, all incurred costs will be included in the claim]. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, details, the nature of services provided, and the amount due.


I am often not immediately available by telephone. While I am usually in my office between 8 AM and 5 PM, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends, holidays and calls made after office hours. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your doctor or the nearest emergency room and ask for the psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.


The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any time spent in preparing information requests.


If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I may also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.


As a licensed therapist, I protect the confidentiality of all the communications with my clients. I will only release information about our work to others with your written permission, or if I am required to do so by a Judge. There are some situations in which I am legally obligated to breach your confidentiality in order to protect yourself or others from harm, including (1) if I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate state agency and (2) if a client is an imminent risk to him/herself or makes threats of imminent violence against another person, I am required to take protective actions. These situations rarely occur, but if such a situation does occur, I will make every reasonable effort to discuss it with you before taking any action.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

Print Name, Sign Name & Date



Nancy Nzioki, Director