Registration

Please register your details before your first appoinment.

Personal Details
Name *
Name
Date of birth *
Date of birth
Residential Address *
Residential Address
Please include country code
Relative / Friend (in case of emergency)
Friend or relative's name
Friend or relative's name
Please include country code.
Family Doctor
Please include country code.
Referral
Referral name (if applicable)
Referral name (if applicable)
Please include country code.
Reason
Shortly describe your reasons for making this appointment.
Conditions
Informed consent for psychotherapy *
Larissa Ernst is a Clinical Psychologist registered with the Psychologencommissie in Belgium and the Health Professions Council of South Africa. Consent for psychotherapy can be withdrawn at any stage in the process. Sessions may be recorded for record keeping purposes. All therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. The following limits to confidentiality applies: When a client is a risk to self or others. When a child (or vulnerable adult) is in danger. When the court orders the psychologist to reveal information.
Cancellation Policy *
If you fail to cancel a scheduled appointment, I cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to illness or an emergency. A bill will be emailed directly to all clients who do not show up for, or cancel an appointment.