Counseling Client Intake Form

Please correct the errors described below.

Professional Disclosure Statement/Informed Consent: I have been working with youth in the Upper Valley in a variety of roles for over 15 years. I have a Masters in Education from New England College and a Masters in Clinical Mental Health Counseling from Northern Vermont University and am a licensed clinical mental health counselor in the State of Vermont.

I’m experienced at building safe supportive relationships with youth, especially those affected by familial substance use and trauma. In my practice I strive to help young people learn effective strategies to cope with trauma, uncertainty and strong emotions so they can find a healthy way forward.

I have a person centered approach to counseling. I use the principles of Cognitive Behavioral Therapy (CBT) which focuses on how our thoughts and feelings affect our behavior, and Motivational Interviewing (MI), which helps a person understand their motivations and identify and act on behaviors they would like to change.

Appointments: Appointments are generally scheduled for 50 minutes weekly. It is very important for scheduled counseling to be kept. Consistent engagement in counseling increases the likelihood it will be effective. In the event you/your child will not be able to attend a scheduled appointment please let me know as soon as you can. If failure to keep scheduled appointments becomes problematic we can talk about how to best proceed, which may include discontinuing counseling until a time when appointments can be consistently kept.

Payment: It is your responsibility to call your insurance company and ask them about a behavioral health coverage/deductible before our first session so you are not surprised by it. Please make payment arrangements with our front office to cover co-pays and deductibles as necessary. If you are having difficulty paying co-pays and deductibles please communicate with our front office to make a payment plan.

Professional Records: A chart of counseling sessions and goals will be kept throughout our time working together. Certain disclosures to your insurance plan are required for determining eligibility for health plan coverage, and billing and receiving payment for your health benefit claims which may include review of services for clinical necessity, justification of charges.

Confidentiality: What is discussed in session is considered to be confidential without client permission to disclose. There are a few times when confidentiality can be broken without consent, as follows: If there is reason to suspect a minor client is being, or has been, harmed (abuse/neglect), is harming someone else, is at risk of imminent harm to themselves or others.

Additionally, if you/your child disclose information to me about another minor, or vulnerable adult, who is being harmed (abuse/neglect) it may be something I need to report. I will always do my best to discuss breaking of confidentiality with a client first.

Release of Information: When working with youth it is often necessary to share, and receive information from, parents and school staff in order to best support a child’s success. To that end I request to have a release of information on file for the child’s school. It is also helpful to have a release on file to communicate with a client’s primary care team.

Consultation/Peer supervision: I collaborate with other clinicians to discuss cases without identifying information. The goal of this supervision is to provide the most effective and helpful services to my clients and to be continually learning from others.

What to expect from counseling: Counseling is a process in which the counselor and client work to resolve problems and meet agreed upon goals. It calls for a very active effort on the client’s part, and the client will have to work on things that are discussed both during sessions and at home. Counseling can have risks and benefits as it may involve discussing unpleasant aspects of one’s life and a person may experience uncomfortable feelings as a result. Counseling has also been shown to help individuals resolve specific problems and reduce feelings of distress.

Telehealth/Telemedicine: Telehealth (or telemedicine) is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when they are located at a different site than the provider.

The federal and state laws that protect privacy and the confidentiality of medical information also apply to telehealth psychotherapy.

When participating in Telemedicine it will be through a video portal that is HIPAA-compliant for security, but there are no absolute guarantees that such technological boundaries cannot be broached or that information will not be lost during technological failures.

Emergency Services: In the event of an emergency, call 911, or Clara Martin Center which is available to you 24 hours a day, 7 days a week. Their Emergency Hotline is 1-800-639-6360 You can also call 988 or use the Crisis Text Line at 741741

Client Rights: Clients have the right to be treated with respect. The state of Vermont requires that I inform clients about my education, experience and policies as well as what their rights are and how to file a complaint about me if they feel their rights have been violated. My practice is governed by the Rules of the Board of Allied Mental Health Practitioners. It is unprofessional conduct to violate those rules. A copy of the rules may be obtained from the Board or online at

If you feel I have engaged in unprofessional conduct please speak to me first. If you wish to file a complaint you can do so at:

By signing below I am acknowledging that I have received, understand, and agree to the policies outlined for counseling above and give permission for myself and/or my minor child, to participate in counseling with Amelia P. Lincoln, MEd, LCMHC. This consent will be valid throughout the duration of therapy.

The purpose of the questionnaire is to help us obtain information about your child and family to aid us in providing the best health care possible. Please answer all questions as they apply to your child. If a question does not apply or you prefer not to answer, leave it blank. If you do not understand a question, please please write don't understand so we can explain it further. This questionnaire will become part of your child’s health record, and as such will be strictly confidential.

Your information will be encrypted.