Therapist Registration Form 2026

Section 1: Personal Details

Full Name

Email Address

Phone Number

Section 2: Location

Where are you located?

South Africa

Rest of World

Section 2A: South Africa Location Details

Province

Practice Address

Availability (select all that apply)

In-person

Online/virtual

Hybrid (both)

Section 2B: International Location Details

Country

City/Town

Time Zone

Practice Address / Office Location

Can you provide online services to youth in South African time zones (GMT+2)?

Yes

No

Limited availability

Availability

Online/virtual only

(International therapists must provide online services)

Section 2: Professional Credentials

Professional Body Registration Number

Professional Body / Council (select all that apply)

HPCSA

SACSSP

ASCHP

CPSC

BHF Practice Number

Other (specify)

Upload Proof of Registration

Highest Qualification

Upload Qualification Certificate

Years of Experience (select all that apply)

0–2 years

3–5 years

6–10 years

11–15 years

15+ years

Section 3: Therapeutic Focus Areas

Specialisation Areas (select all that apply)

Depression & Anxiety

Trauma

Abuse & GBVF

Youth Counselling

Addiction/Substance Use

Grief & Loss

Relationship/Family Issues

Pastoral/Christian Counselling

Other (specify)

Age Groups You Work With (select all that apply)

19–29

Adults 30+

Adolescents (13–18)

Any adult

(Note: SLF only refers 19–29)

Section 4: Payment Options

Counselling Arrangement

Pro Bono Only

Paid Only

Both Pro Bono & Paid

If Paid or Both, select your fee range (per session)

R150–R250

R250–R400

R400–R600

R600–R850

R850–R1200

Above R1200

Do you offer a sliding scale for financially vulnerable youth?

Yes

No

Case-by-case

Section 5: Christian Ethical Alignment

Are you comfortable providing therapy within a Christian, faith-affirming ethical approach?

Yes

No

Integrative approach is preferred

Ministry/Church Affiliation (optional)

Section 6: Safeguarding Declaration

Safeguarding & Ethical Commitment

I confirm that:

I will uphold the safety, dignity and confidentiality of every young person referred.
I will practice strictly within my professional scope and qualifications.
I will report any safeguarding concerns immediately to the Shekinah Legacy Foundation.
I will not engage in emotional, spiritual, sexual, financial or psychological abuse.
I consent to my details being used for referral purposes only.
I understand that violating this safeguarding principle may result in removal from the SLF directory.

I agree to the safeguarding clause.

Digital Signature (full name)

Section 7: Consent & Visibility

May we list you publicly on our website?

Yes, with full contact details

Yes, but only with my practice name & email

No, internal referrals only

Additional Notes or Comments

Shekinah Legacy Foundation