Intake & Consent Form - thetinyroomtherapy.com

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The Tiny Room Counselling & Therapy (practice no. 1013505).

By completing this form, you (or your legal guardian) enter into an agreement with The Tiny Room and your booked practitioner.

Key Information

Fees:

Tween & Teen Therapy (Gr4-17yrs): R795 per 55 minute session
Individual Therapy (18yrs+): R695 per 55 minute session
Couples Therapy: R975 per 60 minute session
Executive Therapy (CEOs, directors, entrepreneurs, executives): R795 per 55 minute session

Payment:

Due by 08:00 the day before your appointment

Clients are responsible for their own medical aid claims

PMB (Prescribed Minimum Benefit) Cover

PMB cover applies only to conditions formally diagnosed by a medical professional (GP, psychiatrist, or psychologist). Our therapists do not diagnose — your diagnosis must come from your treating doctor.

If you intend to use PMB cover for your sessions, please complete these steps before booking in:

Confirm with your medical aid that procedure code 89205 can be approved under your PMB cover.
Email your proof of diagnosis to [email protected] - we will complete the practice's section of your application.
Once your medical aid issues your PMB approval letter, check that code 89205 is listed on it, and email us a copy.

Sessions booked before PMB approval is confirmed are payable at our standard rates, claimable by you from your available benefits. If your approval letter arrives without code 89205 listed, contact us - we will assist you in motivating for it to be added.

Cancellation & No-show Policy:

Cancellations or rescheduling of any appointments need to take place on the working day before your appointment between 07:00 and 15:00.
Cancel at least 24 hours before your appointment to avoid being charged.
No-shows and late cancellations will be charged at the full session rate.
If you are 5 to 15 minutes late, the full appointment time will not be extended. Another client is booked in the slot after you.
If you arrive more than 15 minutes late, our front gate will be closed, and the session will be forfeited and charged as a no-show.

Location:

34 La Provence Rd, Vosfontein, Bellville, Cape Town, 7530

Online sessions available worldwide

Questions?

[email protected]

Agreement*

I have read and agree to the terms above.

Client Occupation*

Age ≥ 18

Partner Occupation

Age ≥ 18

Current School

Age < 18

Referral Source*

Word of mouth*

Reason(s) for Therapy*

Anxiety / Panic Attacks

Depression / Low Mood

Stress / Burnout

Trauma / PTSD

Grief / Loss

Anger Issues

Mood Swings

Low Self-Esteem / Confidence

Suicidal Thoughts / Self-Harm

Have you experienced suicidal thoughts in the past 3 months?*

Reason for Therapy – Details

Diagnosis / Medication

Any professional diagnosis or prescribed medication?

Yes

If Yes, please specify:

Emergency / Next-of-Kin*

First Name Surname

Next-of-Kin Email*

Next-of-Kin Address*

Street Address

Relationship to Client*

Next of Kin Relationship (Other):*

Emergency Contact No.*

Do you have medical aid?

I have Medical Aid

Medical-Aid Name*

Medical Aid (Other):

Medical-Aid Option / Plan*

Medical Aid Scheme (Other):

Membership Number

Are you the main member?

Main-Member

First Name Surname

Main Member Email*

Main-Member ID Number

Medical aid Dependent Number

Please enter a number less than or equal to 9.

Note: clients submit their own claims; procedure code 89205

Tiny Room - Intake & Consent Form

Key Information

Fees:

Payment:

PMB (Prescribed Minimum Benefit) Cover

Cancellation & No-show Policy:

Location:

Questions?

Get In Touch

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