Client Registration Form Date / Time A. IDENTIFYING DETAILS Date * Date when completing the form Name * First Last ID nr. * Gender * Male Female Postal Address Email Address * Occupation: Marital status: Home Language Residential address: * Work tel.: Religion: Race: Date of Birth * Work address: Cell: * Church: SPOUSE OR PARTNER DETAILS Name First Last Cell: Gender: Male Female Occupation: Marital status: Work tel.: Home language: Religion: Race: Email: Date of birth: Church: CHILDREN Name First Last Date of Birth Name First Last Date of Birth Name First Last Date of Birth Name First Last Date of Birth B. EMPLOYER DETAILS Name of Company: Section: Name of manager/supervisor: Contact no.: C. REFERRED BY Self: Manager/supervisor: Colleague: Company clinic: Social worker: HR: D. NAME OF FAMILY MEMBER OF CLOSE FRIEND Name First Last Tel.no. Relationship E. OTHER PROFESSIONALS INVOLVED(E.g. Doctor, Psychiatrist, previous counsellor) Name First Last Tel.no. Capacity Name First Last Tel.no. Capacity F. Medical aid Information Medical aid scheme Name : Member number: Main member: Name of beneficiary: First Last Member number: Name of beneficiary: First Last Member number: Name of beneficiary: First Last Member number: Name of beneficiary: First Last Member number: Name of beneficiary: First Last Member number: Please agree to the following (Compulsory) * All information supplied above is true to the best of my knowledge. I have read the office regulations regarding the Covid-19 virus. I understand that I am the responsible person regarding the payment and claimant of ALL fees involved, except if other arrangements were made prior to my appointment. I understand that all fees must be paid in full before consultation and that these funds will be forfeited if the appointment was cancelled by you WITHIN 24 HOURS BEFORE the appointment. If you reschedule your appointment within 24 hours of you appointment an administration fee of R200-00 will be charged.
