Copy of COUNSELLING FORM | Rare Diseases SA

RARE ASSIST AD-HOC QUERY

Counselling will be offered telephonically, or via a secure online platform, as we know mobility, and getting around is often challenging for many of our families.

Various counselling is available:

Grief / Bereavement
Relationships
Work related challenges
Child Counselling
Abuse & Trauma
Crisis management
Coping skills and stress management

Counselling Registration Form

Patient's First Name

Patient's Last Name

Patient's Email

Patient's Contact Number

Patients' Address

Patient's Birthday

Patient's Gender

Patient's Home language

Patient's Race

Age of Patient

What is your Medical Diagnosis?

Background information and reasons to want to start counselling?

Are you a member of a dedicated support group?

Yes

No, but would like to be

Would you like us to place you in touch with other patients with similiar disorders/Symptoms?

Yes

Is there any other information you feel we should be aware of?

Full name of Guardian (in case of minor) / Emergency Contact

Relationship to Patient

Email for Next of Kin

Contact number of Next of Kin

Full name of Patient's primary treating doctor?

Physical Address of treating doctor

Email of treating doctor

Contact Number of treating doctor

I consent to receive counselling services from a student counsellor from the Vita Nova Counselling centre. The sessions may take place via telephone or Zoom and are confidential. Confidentiality means that everything discussed in all sessions will remain strictly between the counsellor and client. Confidentiality will not be upheld in the following circumstances: 1) If the counsellor discerns the client is a danger to themselves or others 2) For supervision purposes. In which case all identifying information about the client will be omitted. 3) If the counsellor or their notes are subpoenaed by a court.

Please note that by clicking submit, you acknowledge that you are sharing confidential information with RDSA and accept RDSA's privacy policy and disclaimer. Privacy Policy: Rare Diseases South Africa (RDSA) respects your privacy and is committed to protect the personal information that you share with us. Our database contains private information including name, address, contact information and medical information. If you provide any private or non-public information it will be restricted to site administrators and individuals on a need-to-know basis and will not be sold or given outside of RDSA without consent from you. Disclaimer: RDSA is a resource for sharing information and support. RDSA members, employees and executive board members do not offer medical advice. The information provided on the RDSA website, newsletter and message board are designed to support, not replace, the relationship that exists between a patient/RDSA member and his/her physician. Please verify any information you receive from RDSA with other sources and with your licensed health care provider. Decisions regarding medical care should be made with your healthcare provider. Consumers should never disregard or delay seeking medical advice due to the content of this website. The RDSA executive and medical boards, volunteers and moderators do not assume, and hereby disclaims, any and all liability to any person or entity for any claims, damages, liability or other loss including, without limitation, any liability for injury or other damage resulting from any use of, or reliance on, this service or from the posting of any content or material by any third party.

Thank you for you registering for our counselling service. You will receive an email shortly with further instructions on how to book your session.

RARE ASSIST AD-HOC QUERY

Counselling Registration Form

Looking for disease related information? Check out our Resource Hub

TELEPHONE +27 72 476 7552

EMAIL ADDRESS

RARE ASSIST AD-HOC QUERY

Counselling Registration Form

Looking for disease related information? Check out our Resource Hub

TELEPHONE +27 72 476 7552

​

EMAIL ADDRESS hello@rarediseases.co.za

EMAIL ADDRESS