Sacred Studios: Intake & Consent Form

Service Type:

IF THE CLIENT IS A MINOR (UNDER 18):

If Seeking Couple’s Therapy

CLINICAL HISTORY & CONTEXT

Data Protection & Secure Storage (POPIA & HPCSA)

Sacred Studios is committed to the protection of your personal and clinical information.

• Secure Storage: I acknowledge and consent that all personal data, including online information, hardcopy documents, physical artworks, and digital photographs of artworks, are stored safely and securely. Virtual platforms and cloud storage (e.g., email or cloud drives) utilize relevant password protections. 
• Compliance: Records are maintained in accordance with the Protection of Personal Information Act (POPIA) and HPCSA ethical guidelines for health records. 
• Client Rights: In line with POPIA and the Promotion of Access to Information Act (PAIA), you retain the right to request access to, updates to, or the deletion of your personal information. 
• Retention: Clinical records are safely retained for the legally required period – 6 years for adults, or until a minor client's 21st birthday – in compliance with HPCSA standards, before being securely destroyed. 

Professional Policies & Informed Consent

Photography of Artworks, Process & Academic Material

Photography of the artmaking process and/or final products is a valuable tool for clinical reflection and the therapeutic narrative.

• Pre-emptive Consent: By signing below, you provide initial, pre-emptive consent for photographs to be taken. 
• Circumstantial Nature: I understand that this consent is fluid. It may be revisited, restricted, or withdrawn at any time for specific artworks or sessions. I retain the right to decide whether any individual piece is documented. 
• Academic & Research Use: Material from the therapy work may occasionally be used anonymously for training, research, or publication purposes, ensuring all identifying data is strictly omitted. (Please note under "Special Terms" at the end if you wish to opt out of this specific academic use). 

Initial here to provide photography & anonymous academic consent:  {name-2}

Financial Policy

Photography of Artworks, Process & Academic Material

• Payment & Medical Aids: Sacred Studios is a cash-based practice. The practice is not contracted into medical aid schemes; clients are responsible for settling fees directly. Clients may independently claim back from their schemes depending on their specific options, though not all medical aids cover Arts Therapies. Fees are adjusted at the beginning of each calendar year. 
• Cancellations: Sessions cancelled with less than 24 hours' notice will be charged at the full rate, as professional time has been set aside. Please note that medical aids do not reimburse for missed or cancelled sessions. 
• Late Payments & Collections: Late payments may incur interest charges. Accounts left unpaid timeously may be handed over for debt collection, and the client will be liable for any associated legal costs. 

Clinical Boundaries & Ethical Limits to Confidentiality

• General Confidentiality: Private therapeutic information is regarded as highly confidential. You have the right to ask questions about anything that occurs in your therapy at any point. 
• Legal & Ethical Exceptions: The therapist may be legally or ethically obliged to break confidentiality and disclose information to relevant third parties under exceptional circumstances: 
  1. If there is a clear, serious risk of harm to yourself or another person. 
  2. If there is reason to believe a child has been or is at risk of being harmed. 
  3. In compliance with a valid court order or subpoena. 
• Termination: Ideally, therapy terminates when both the client (or guardian) and the therapist agree that therapeutic goals have been achieved. 

Couples & Group Specifics

• Couples: We understand that information shared in individual "side-conversations" may be brought into joint sessions if deemed clinically necessary by the therapist. 
• Groups: I agree to keep the identities and personal stories of all group members strictly confidential. 

Formal Agreement & Signatures

Parental Consent (For Minors)

I/We, the undersigned, confirm that I am/we are the legal guardian(s) of the minor named above. I/We consent to their engagement in Art Psychotherapy. I/We understand that clinical details remain confidential between the therapist and minor unless a risk of harm is identified. 

Guardian Signature:  {name-1}  Date:  07/27/2026

Secondary Guardian Signature:  {name-3}  Date:  07/27/2026

General Consent (All Clients/Guardians)

I enter this therapeutic relationship voluntarily. I have been informed of my rights, the nature of the creative process at Sacred Studios, and the policies regarding data storage, confidentiality limits, and financial responsibility. By signing below, I acknowledge that I have read, understood, and agreed to the terms of this contractual agreement. 

Client Signature:  {name-2}  Date:  07/27/2026

Guardian Signature:  {name-1}  Date:   07/27/2026

Partner Signature:  {name-4}  Date:   07/27/2026

Date:  27/07/2026