This agreement is between a Specialist Wellness Counsellor and the undersigned parents / legal guardians of the minor child concerned.

Agree to the following conditions of service delivery:

1. Please take note that the Children's Act states that in the case where parents are divorced, both parents need to give consent for any intervention or assessment of their child, as both parents have equal parent responsibilities and rights. Counselling for the minor therefore cannot take place if both parents have not signed this form.
2. I hereby indemnify the undersigned specialist wellness counsellor from any claims that may arise due to any loss or damage to me and/or my family and/or my property during and after service delivery.
3. I understand that no report will be compiled by the specialist wellness counsellor as part of the counselling involvement with the child.
4. If a report is required as part of statutory or legal processing the relevant parties need to request it in writing through their legal representative. I take note that additional fees will apply. I understand that no recommendations outside of the original mandate of involvement, in this case the counselling intervention can be made.
5. Due to the confidential nature of the services being rendered I understand that the specialist wellness counsellor will communicate with me through their preferred method of communication. If I feel the need to relay any important information, new developments, or other information I will do so via email or request a consultation with the specialist wellness counsellor.
6. I understand that normal client-counsellor confidentiality will apply. The specialist wellness counsellor will however, give me regular feedback as the need may arise on any information pertaining to the minor child that I, as a parent should, be aware of.
7. I understand that no information regarding counselling intervention can be made available to a third party without the consent of both parents.
8. I understand that the undersigned specialist wellness counsellor is under both ethical and legal obligation to report any knowledge of sexual or physical abuse to SAPS as well as the local welfare organization.
9. I take note that I have the right to report any professional misconduct of the specialist wellness counsellor at the SACSSP. I take note that the specialist wellness counsellor and/or any other professional involved in her team have the right to lay a civil charge against me should he/she be found not guilty by the council.
10. I hereby request and/or agree that the undersigned specialist wellness counsellor continues with counselling intervention with the minor child.