Mediation Client Information

"*" indicates required fields

Date
Mediation type

Client 1 Information

Name
Date of birth
Home address

Client 2 Information

Name
Date of birth
Home address

Child 1

Name
Date of birth

Child 2

Name
Date of birth

Child 3

Name
Date of birth

Child 4

Name
Date of birth

Legal matters

Are you currently involved in divorce proceedings?
History of Domestic Violence?
Protection Order/Interdict
Date of Order

Other

Alcohol or substance difficulties?

Electronic copies of relevant documents and reports

Protection Order
Max. file size: 32 MB.
Marriage Contract
Max. file size: 32 MB.
Final Order of Divorce
Max. file size: 32 MB.
Parenting Plan
Max. file size: 32 MB.
Forensic Report
Max. file size: 32 MB.
Assessment Report
Max. file size: 32 MB.
Diagnostic Report
Max. file size: 32 MB.
Max. file size: 32 MB.

Payment of consultations and administrative work

1. Hitchcock Mediation and Therapy is a cash practice.

2. Therapy fees are payable when making the appointment or on the day of the appointment. If applicable, claiming from your medical insurance is the client’s own responsibility.

3. Payment options available: EFT, CC, Payfast….

4. The clients involved are fully responsible for payments and should they not pay timeously, they will be liable for debt recovery and legal costs.

5. A full consultation fee will be charged for appointments not kept or cancelled within 24 hours of the consultation date.

Privacy of personal information

CONFIDENTIALITY RELATING TO MEDIATION AGREEMENTS AND RELEVANT DOCUMENTATION

1. All information handled by the practice is regarded and treated as strictly confidential by the family mediator and the practice staff. Legislation compels the practice to provide certain information on accounts, including diagnostic information.

2. Mediation is not covered by medical insurance.

3. The Practice must also disclose ICD-10 codes on referral letters to other clinicians.

4. In the event of a third-party request for confidential information from the practice, and in doubt regarding the safety of confidentiality processes, the practice may insist on following the standard operating procedures legislated in any legislation.

5. You hereby consent in terms of the Protection of Personal Information Act 4 of 2013 (“POPIA”) as amended from time to time, that the practice may share your personal information (including diagnostic information) for practice administration services, including external practice administration providers contracted by the practice, historical, statistical, research purposes, or practice business planning with other service providers to enhance systems and services, this to include sharing with the personal information with other Healthcare and Legal Practitioners, Claim/Invoice Switch Houses in the course of providing the services to you. Your participation in this regard is highly appreciated.

6. Your personal Information will be securely retained by the practice for a period of no longer than 5 years after your last visit to the practice, or as required by legislation if longer than this period. The Practice shall not transfer or authorise the transfer of Personal Information to countries outside of the Republic of South Africa without your prior written consent (which written consent you hereby provide in terms of section 72(1)(b) of POPIA to allow such transfer outside the Republic of South Africa) for the purposes as defined in the POPIA and specifically to provide the required services to the Practice and to you.

7. If Personal Information processed under this Agreement is transferred from the Republic of South Africa to third party in another country, the transferring Party shall comply with sections 72, 57 and 58 of POPIA.

8. This portion of this Agreement is only applicable to Practices with their Data Subject's PI (your PI) located within the jurisdiction of the POPIA.

9. You further hereby consent that the Practice may contact you by any one of the following communication methods/platforms/systems (“communications”); namely: phone, sms, Email, social media platforms such as WhatsApp, Telegram, Signal or similar services or any future communications. You understand that these communications will be used for professional communication only. This will include (but not be limited to) accounts, statements and information, practice information, system updates, professional updates and reports where necessary and indicated. You acknowledge that none of these communications are completely secure or encrypted communications, and you will not hold the Practice responsible for any breach of confidentiality via these communications.