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Partner 1 Details

Biographical Information

Contact Information

Emergency Contact Details

Partner 2 Details

Biographical Information

Contact Information

Emergency Contact Information

Medical Aid Details

Therapy is a relationship in which both the psychologist and the couple have rights and responsibilities in order to facilitate the successful outcome of the intervention. This contract serves to clarify these rights and responsibilities.


  1. Benefits of Couple’s Therapy

The Key benefits that couples can and have reaped from Therapy are: -

  • Bringing positivity and safety back into your relationship
  • By so doing reconnection is able to happen
  • Learning to be the safest partner possible to be able to give and receive love and therefore creating space for connection to grow
  • Discover new communication skills to redirect the  negative energy from arguments to create passion and stability in the enhanced relationship.
  • Equip yourself with tools for re-romanticizing your relationship to re-establish the passion that you remember from your past together.


  1. Approach to Therapy

The primary therapy model I use is Imago Therapy which I intersperse with cognitive behavioural and varies therapy modality. This approach helps a couples understand that the unconscious forces that attract you to your partner which are also the source of conflict. My role is to guide the process, keep the area between you safe and share my knowledge. Your role is to talk to each other, do the homework agreed to and commit to the full treatment.


In order to focus our work together I require a 90 day commitment. In those three months we will schedule six (6) sessions of 90 minutes long.  These will happen every second week and in between that you will be practicing and doing your homework. At the last sessions we can decide as a collective whether to proceed or not.


  1. Responsibility of the Therapist
    • Neutrality and Guidance

My key responsibility is to be a guide to your process and maintain an equal balance between understanding, compassion, limit setting and knowledge sharing of observations and directional prompts. I equally need to maintain a balance between educating and helping you process information. Additionally, I am committed to providing clear homework assignments and supporting attempts at change. I will be direct, supportive and encouraging ensuring I create a safe working space.


  • Confidentiality

All information will be kept confidential between me and you as the couple with the following expectations

  • Abuse of Minor or Elderly

Confidentiality does not apply to cases of acknowledged or suspected neglect or physical or emotional abuse or abduction of children under the age of 18.

Furthermore, confidentiality does not apply to cases of acknowledged or suspected financial or physical abuse, abandonment, isolation or abduction of elderly or dependent adult.

In such cases I am required by the law to file a report with the appropriate governmental agency. Once the report is filed, I may be required to provide additional information.


  • Potential Harm to self or other

If you threaten to harm yourself, I am obligated to seek hospitalization for you or to contact family members or others who can help provide protection.

Furthermore, if you communicate a serious threat of physical violence against an identifiable victim potentially or harm others, I must take protective actions, including notifying the victim and or contacting the police. I may also seek hospitalization for you or contact others who can assist in protecting the victim.


  • Law/ Court Subpoena

I may disclose confidential information in court proceedings as mandated by the law or in protection of proceedings brought against me by yourself in defense of myself as a professional.  I may be required by law to appear as a witness in court matters concerning one or both of you, however in such cases the psychologist will indicate that they are appearing as an unwilling witness.

If you are already involved in court proceedings, please seek a legal opinion before signing this document.


  • Emergency

Confidentiality may be broken in the case of an emergency and consent cannot be obtained. The people specified in my client form will be contacted.


  • Payment

Disclosure of personal details may occur in order to obtain payment for psychological services. The collection agency with whom I work has committed to maintain confidentiality of the data.


  • Collection and Storage of Information

Storage and collection of client information is in accordance with the Protection of Personal Information Act (POPI), the Constitution of South Africa, 108 of 1996 and in accordance with guidelines of the Health Professions Council of South Africa (HPCSA). I keep two sets of professional records, viz; clinical records and therapy notes.


Clinical records include – reasons for therapy, goals of treatment, progress on goals, medical and social history, treatment history, treatement records from other providers, billing records, diagnosis where necessary. You are entitled to these records except in instances where my judgment tells me that these may be misinterpreted or upsetting to an untrained eye. In this case should you wish to review your file I recommend you do so in my presence or the presence of a fellow psychologist. Written request of the latter is required. I am obliged to keep the records for six years., after which they will be destroyed.


Therapy notes – the notes are my analysis of the sessions and are for my own use and are designed to assist me provide the best treatment to you. They may also contain confidential information you shared in therapy. These are only available if subpoenaed by law.


All records are stored securely on my premises and reasonable steps have been taken to secure them, baring a robbery or fire and or permissible confidentiality breach (as stated in 3.1) there should be no breach of confidential information.


Please note however that if you elect to communicate with me via email or WhatsApp, this is not a completely secure and confidential medium and such cannot be guaranteed.


  • My Availability

This therapy relationship is between me and yourself as a couple. In order to maintain my objectivity, I am available to both of you and will therefore prefer that our contact is primarily in the session. If the need arises for any communication outside the session or with only one party of the couple, we will agree together prior to this happening.


My preferred communication methods are SMS or WhatsApp, and I will respond within 24 hours.


My office hours are from 17:00 – 20:30 (Mondays – Fridays) and 10:00 – 16:00 Saturdays.


  • Contact with other Health Professionals

From time to time it may be necessary to discuss your case with my Supervisor as is required. The purpose of this discussion will purely be for the purpose of improving my service to you – names will be kept confidential.


Additionally, it may be helpful to contact other health professionals whom you have utilized e.g., doctors – permission will be sought with yourself prior to doing so.


  1. Responsibility of the Couple (individually and collectively)
    • Keep the 90-day commitment
    • Keep arrive on time to all appointments
    • To keep all scheduled appointments and payments per session
    • To follow directive of the therapist and stay in process
    • To be open curious about my partner’s reality
    • To be willing to take responsibility for your part of the situation
    • To express complaints discomfort to either your partner or to the therapist in the session and no other third party, friends or family
    • To NEVER NEVER use material from the session against your partner
    • To take the risk to be vulnerable at whatever level stretches you but does not break you
    • To be respectful of your partner in and outside the session
    • To refrain from contacting the therapist outside of sessions by email or phone unless it is to inform of administrative matters e.g. the actual appointment



  1. Fees and payments

The fees are R1200 for a 90-minute session of couple therapy. This practice is a cash practice. Clients are required to settle their account in full after every session and to then claim from their medical aides. An invoice will be emailed to you after the session. I am obliged to include an ICD-10 code to third parties for medical aide.


Fees are in line with current medical aid rates. Fees for referral letters, reports and any other requested documentation will be charged prorated my hourly fee.


A 24-hour notice period is required for cancelation of appointments, otherwise the full session fees will be charged. No shows will be treated in the same manner, full fees will be charged. However, if appointments are continually cancelled, we will have to reconsider our agreement and discuss an honest way forward.

Payment to be made to:-

Linda Mthenjane

RMB Fusion Account




  1. Consent

I have read this document had sufficient time to be sure that I considered it carefully, asked any questions that I needed to and fully understand it. I understand the limits to confidentiality required by the law. I understand the rights and responsibilities of us as a couple and those of my psychologist. I agree to undertake therapy with Linda Mthenjane a clinical psychologist.

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