Registration

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Friend or relative's name

First Name

Last Name

Referral name (if applicable)

First Name

Last Name

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 Consent for psychotherapy can be withdrawn at any stage in the process. 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.

I accept the conditions of consent to psychotherapy

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.

I accept the conditions of the cancellation policy

Recording sessions *

Sessions may be recorded for record keeping purposes.

Yes, I consent

No, I don't consent