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1. Personal Information

Child's Details

Child's Full Name *

Date of Birth *

School *

Grade *

Teacher *

Teacher's Email *

Extra Murals

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Mother's Details

Mother's Full Name *

Occupation *

Address *

Employer *

ID Number *

Email *

Cell Number *

Is the child’s mother is responsible for this account?YesNo

Signature *

Father's Details

Father's Full Name *

Occupation *

Address *

Employer *

ID Number *

Email *

Cell Number *

Is the child’s father is responsible for this account?YesNo

Signature *

Medical Aid Details

Name of Medical Aid *

Medical Aid Number *

Please note that Playwrite Occupational Therapy is a cash practice. Please settle your account with your therapist and then submit the account to your medical aid to be reimbursed, if applicable.

Name of Doctor *

If you would like anyone else to receive your child’s OT reports, please advise below:

Name

Profession

Name

Profession

Name

Profession

Name

Profession

2. Cancellation Policy

Please note that we require 24 hours of notice should your child not be able to attend their scheduled appointment. Exceptions will be given when a child is sick or in the case of a family emergency. Should notice not be provided, sessions will be charged for in full.

3. Fees

Accounts will be sent out on the 25th of each month and should be settled via EFT upon receipt. Below, please see the fees and discounts for 2026.

Treatment Code	Description	Fee
66311	30-minute individual therapy session	R410,00
66315	45-minute individual therapy session	R615,00
66318	60-minute individual therapy session	R820,00
66108	30-minute consultation or meeting (including school visits)	R410,00
66109	15-minute consultation or meeting (including school visits)	R205,00
66111	Summary Report (not claimable from medical aid)	R600,00
66111	Comprehensive Report (not claimable from medical aid)	R1200,00

A sibling discount of 15% per session is applicable for families where more than one sibling is being seen for occupational therapy within the practice. In situations where parents are divorced, we are unfortunately not able to split accounts. Please note that should your account reach 30 days overdue, treatment will be suspended until the account is settled in full.

4. Disclosure of Information

Occupational therapy is a health science, and as such, your occupational therapist is governed by the Health Professions Council of South Africa (HPCSA). According to the HPCSA guidelines, a copy of your child’s occupational therapy report will be sent to his/her doctor for their medical file. Please complete the below statement regarding the sharing of pertinent information with your child’s educational team:

parent/guardian of;

dodo not

give permission for my child’s occupational therapist to share these reports with his/her school and other relevant health professionals.

5. Reports

Unless otherwise discussed and agreed upon, a report will be given upon assessment and completion of therapy. If additional reports are requested, a minimum of three weeks notice is required. Additional formal reports will be charged at R600 each.

6. School Visits and Feedback

A school visit for your child will take place at least once every four months and verbal feedback with the teacher will take place at least once a term. Verbal feedback with the child’s parents/guardians will be arranged once a term. It is recommended that both parents attend meetings together. School visits will be charged at R300 per 30-minute school visit and any consequent feedback session will be charged at R300 per 30 minutes and an additional R150 per extra 15 minutes.

7. Injuries

Everything will be done to ensure the safety of your child whilst in the Playwrite therapists’ care. However, neither the therapists, nor any other persons on the premises, may be held responsible for any injury or mishap, including loss or damage to property, be it in or outside of the treatment area.

8. Acceptance of Terms of Therapy

We, the parents/guardians of (child’s name)

, confirm that we have read, understood and accept the terms of therapy as stated above.

9. Protection of Personal Information (POPI) Act

Your privacy is important to us. We want to communicate with you and deal with your personal information with your consent and in line with South African privacy law including the Protection of Personal Information Act (POPIA). Please sign below to consent to us processing your personal information. Our Privacy Notice added as an addendum to this contract, contains further details on how we process your personal information.

I am aware of the following regarding the practice’s POPI Act policy:

We collect and store the information about you for us to adhere to the administrative requirements of the practice.
We collect and store information about you for us to continually assess, treat and manage your child’s clinical best interest.
We will use your personal information only for the purposes for which it was collected and agreed upon with you.
We may disclose your personal information to our service providers who are involved in the delivery of services to you (i.e. for billing purposes). We have agreements in place to ensure that they comply with the privacy requirements as required by the Protection of Personal Information Act.
We will, on an ongoing basis, continue to review our security controls and related processes to ensure that your personal information remains secure.
You have the right to request a copy of the personal information we hold about you. Please note that any such access request may be subject to payment of a legally allowable fee.

10. Communication Preferences

Invoices and secure information such as reports will be sent via email. Please tick your preferred method of daily communication:

EmailWhatsAppSMS

Mother's Signature

Father's Signature

Contact Details

Full Contact Name *

Contact Phone Number *

Contact Email Address *

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