Confidential Client Intake Form


SHERRI ROBBINS, MA, LGPC, LCMHCA
PROFESSIONAL DISCLOSURE STATEMENT

The counseling process is a working relationship that is most effective when clients understand their rights and responsibilities, along with what to expect from the therapist and counseling experience. By knowing your rights and defining roles, it creates a safe environment for you to maximize the benefits of counseling and empower you to grow in mental wellness. The following information provides you with an overview of my responsibilities as a counselor, along with your rights and certain limitations that you should be aware of.

I. Introduction

I am honored that you have chosen me as your counselor. The information provided is to make you aware of my professional background, in addition, to educating you on the counselor/client relationship. I have a Master’s Degree in Clinical Mental Health Counseling from Regent University. I am a Licensed Graduate Professional Counselor in the state of Maryland and a Licensed Clinical Mental Health Counselor Associate in the state of North Carolina. I am also clinically trained in EMDR Therapy.

II. Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally, I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of therapy, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of therapy.

III. Counseling Services Offered/Theoretical Approaches

Counseling is a process that takes time and commitment from both the client and the counselor. The client will be asked to do personal homework, such as; working on areas of struggle and relationships outside of the counseling session, identifying personal triggers, and/or keeping a journal. These assignments allow the client to, put into practice, skills, and strategies that are addressed within the sessions. In order to maximize the benefits of counseling, it will require the client’s dedication to make a long-term commitment to change.

I provide individual therapy for both adults and adolescents, in addition to marriage and family therapy. My main approach to counseling is through a form of Cognitive-Behavioral Therapy called Acceptance and Commitment Therapy. I also provide EMDR Therapy for clients who need help processing traumatic events. I use Gottman Marriage Therapy and a family systems approach when working with couples and families. For those seeking therapy with Christian integration, I am happy to include that within therapy sessions. It is beneficial for clients to understand the type of therapy that they are receiving. For more information on Acceptance and Commitment Therapy, Gottman Marriage Therapy, and EMDR, please visit my website at http://www.sherrirobbins.com.

Therapy by Telehealth

Telehealth has certain benefits and risks. It is a convenient way to continue to receive counseling services and can be highly effective. Agreeing to Telehealth assumes the following:

1. I understand that I am responsible to meet in a confidential setting and assume the risks for this.

2. I understand that my therapist will take every precaution to provide confidentiality. However, I also understand my therapist cannot 100% guarantee confidentiality through Telehealth.

IV. Length of Sessions

Counseling sessions begin promptly and are conducted in a proficient manner. Individual sessions are for a duration of 50 minutes. When scheduling your appointment, please make sure that it is a time that you can commit to. In the event that you need to cancel an appointment, please be sure to give a minimum of 24-hour notice. If you cancel at the last minute or neglect to show up for your appointment, a fee of $50 will be charged.

V. Insurance

I currently do not take insurance and am considered out of network. If you have health insurance with out of network benefits, I can provide receipts for you to submit for insurance reimbursement. Most insurance plans require a diagnosis as part of filing a claim. This diagnosis will become a part of your permanent medical record. You are responsible to obtain any pre-certification for intensives without my assistance. Please understand that verification of benefits or pre-certification of services does not guarantee that an insurance carrier will cover this type of outpatient intensive service, and you agree to pay for these services in advance.

VI. Fees/Methods of Payments

Individual 50-minute sessions are $100. Marriage and Family sessions are 50-minutes and cost $125. Many couples and families find they need longer sessions. 80-minute sessions are available upon request and cost $187.50. Payment is due at the conclusion of each session. Payments can be in the form of credit card, cash, or a check made payable to Sherri Robbins. Teletherapy may only be paid by credit card.

VII. Explanation of Multiple Relationships

The counselor and client relationship is professional in nature and has restrictions. This means that we will not be in contact outside of the counseling session, with the exception of communicating to schedule appointments or ask questions pertaining to the counseling appointment. The information you share is very personal and intimate, so it is important that you are aware that our relationship is professional. As a counselor, I cannot have a social relationship with you. This means I cannot accept gifts of value greater than $50, social media invitations, and personal invitations outside the counseling sessions. This is for your protection as the client and it ensures that you receive the most professional care.

VIII. Solving Problems

If you have an issue with me during your therapy process, I want to help you work through it. Please do not hesitate to openly discuss your concerns with me. If you feel you have a concern that cannot be resolved with me, you are free to contact my supervisor, Monica Mouer, LCMHCS. Monica can be reached at her office, (704) 237-4042. If you do not believe your issue can be resolved by me or my supervisor, you are welcome to contact the appropriate licensing board.

Maryland Board of Professional Counselors and Therapists
4201 Patterson Avenue, Suite 316, Baltimore, MD 21215
Telephone: (410) 764-4732
Fax: (410) 358-1610

North Carolina Board of Licensed Professional Counselors
P.O. Box 77819, Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007
Fax: 336-217-9450
E-mail: complaints@ncblpc.org

Sherri Robbins, LGPC, LCMHCA
Maryland License Number LGP9413
North Carolina License Number A1484


Contact Information


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Personal History Questions

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By signing this intake form, you are acknowledging that you have read and understand the personal disclosure and practice policies, and agree to the terms of professional counseling with Sherri Robbins, MA, LGPC, LCMHCA.