*Please note: Email correspondence is not considered to be a confidential medium of communication. 

 

Christina A. Herbin MA, LPC, NCC

License # 6401013340

 

I. Name and Address:

Christina A. Herbin

321 S. Main St. Suite 215

Phone: 734-644-6943

Ann Arbor, MI 48104

II. Description of Practice:

Counseling involves the sharing of personal concerns or issues with a professional who is skilled at helping the client or clients come to a resolution or solution about their presenting concerns. The therapist and client work together to identify the necessary tasks or goals needed to resolve a presenting concern. Counseling is a relatively short-term, interpersonal; theoretically-based process guided by ethical and legal standards that focuses on helping individuals resolve developmental concerns, situational difficulties, and more complex psychological disturbances.

My therapeutic technique is provided through a strength-based framework. I strive to identify the strengths in each of my clients, despite any past or present adversities. My theoretical orientation is an eclectic approach, which utilizes cognitive-behavioral therapy, play therapy, trauma-focused cognitive-behavioral therapy (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR) and brief therapy techniques to achieve positive treatment outcomes and goals. The combination of therapeutic techniques ensures that each client can gain practical skills to assist with daily life. Most importantly, I emphasize rapport building, unconditional positive regard, and empathy with each of my clients. We will work together to develop the best course of treatment depending on your needs.

III. Education and Experience:

I have a Master of Arts in Counseling Psychology with specialized training in Mental Health Counseling from Boston College. My graduate institution offered curriculum heavily devoted to social justice and multicultural competence. I am skilled at providing therapy to children, adolescents, and adults from diverse populations and advocating for their needs. Thus, I utilized my advocacy and strength-based skills while working with clients who are experiencing emotional and behavioral difficulties.

IV. Fee Scale:

Sessions will last approximately 50 minutes and will be billed at a rate of $210. A 30-45 minute session will be billed at a rate of $180. A sliding scale fee (based on income) is available for clients who are unable to pay the full fee. Cash, credit card or personal checks are acceptable for payment at the time services are rendered. I may use and disclose medical information about a client such as diagnosis, services, and other identifying information to a third-party payer (e.g., insurance companies) to arrange payment.

V. Code of Conduct:

The State of Michigan requires counselors to adhere to a specific Code of Conduct that is determined by the Board of Counseling. I am a Licensed Professional Counselor (LPC) for the State of Michigan. I am subject to the Code of Ethics of the Michigan State Board of Examiners of Professional Counselors. If at any time, you feel my behavior or my counseling approach is inappropriate or troubling to you, please let me know. If however, you do not feel your concerns are being addressed appropriately, and wish to file a complaint, please do so through:

Michigan Department of Licensing and Regulatory Affairs Enforcement Division Allegation Section

P.O. Box 30670

Lansing, MI 48909

517-373-9196

VI. Your Right to Privacy and Confidentiality:

The contents of counseling, intake, or assessment sessions are confidential, both verbal and written. This information will not be shared with a third party without the written consent of the client or the client’s legal guardian without a written release; However, there are several circumstances that I cannot guarantee confidentiality legally and/or ethically: 1) If I have sufficient evidence to believe that you are in imminent danger of yourself or another person; 2) If there is sufficient reason to believe a child or elderly person is in danger of neglect or abuse; 3) In rare circumstances Professional Counselors can be ordered by a judge to release information. Otherwise, I will not tell anyone anything about your treatment, diagnosis, history, or even that you are a client, without your full knowledge and a signed Release of Information Form.

VII. Emergencies:

If you are experiencing an emergency, you may reach me by calling (734) 644-6943. If you are in crisis and need immediate assistance, please dial 911 or go to the nearest Emergency Room. If you are having thoughts of suicide, Please call the: National Suicide Prevention hotline or the National Hopeline Network. Toll-Free 24/7 support is available:

     1-800-273-TALK                                                  1-800-SUICIDE

    1-800-273-8255                                                 1-800-784-2433

   National Suicide Prevention                     Lifeline National Hopeline Network

VIII. Client responsibilities:

If you are unable to keep an appointment please call me to cancel at least 24 hours in advance to avoid paying the total fee for the session. In cases of emergency weather or illness, I will work with you in negotiating exceptions to this policy.

IX. Physical Health:

It is suggested that you obtain a complete physical exam from a qualified physician. Also, please disclose all medications you are currently taking.

I have read and understand the Declaration of Practices and Procedures.

 

 

I hereby consent to participate in telemental health with my provider as part of my psychotherapy. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risk and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (e.g., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.

6) I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart session. If we are unable to reconnect within ten minutes, please call me at my above phone number to discuss since we may have to re-schedule.

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.