This page is for existing or potential clients, not meant for the general public. If you have reached this page in error you can exit or go back to any other page. In this section of the therapy program and treatment plan, I will cover the process of the intake sessions, and your onboarding & orientation to therapy. It is essential to your treatment and the therapeutic journey that I let you know why you are being asked to review this material. I will let you know what you can expect for the next steps in this process. You’ll learn why following the therapy program and creating an individual treatment plan is important. During the intake sessions, I’ll cover the process of making the plan and each element of an effective plan.

The intake session is the foundational step in beginning therapy and developing your treatment plan. It serves as an opportunity for you and I to establish rapport, gather relevant background information, assess your needs, and set initial therapeutic goals. This process can typically take 2 or more sessions, lasting 55 minutes, depending on the complexity your history and presenting concerns. At the start of each session, I will ask you to briefly check in with your current emotional, mental, and physical state, and review the next step of the therapeutic process. This discussion helps to create a safe and transparent environment where the client can feel comfortable sharing their experiences.

W will then begin exploring your reason for seeking therapy. This includes discussing current stressors, symptoms, emotional or behavioral challenges, and specific concerns that led them to seek help. I will ask about your history with mental health treatment, including any prior therapy, psychiatric diagnoses, hospitalizations, or medication use. Understanding past experiences with mental health care allows me to build upon what has worked and avoid approaches that have been ineffective.

I will share the necessity of complying with ethical standards, state licensing regulations, federal and state laws, and health insurance company requirements. I will explain the process of gathering information from you, including a history, current problems, and a list of medications. I will explain what medical necessity is and why it’s important. I will review the informed consent to treatment, our therapy agreement, the intake session, and the intake process. You will learn why critical thinking skills are foundational to my therapy program, your treatment plan, and the health and wellness program. I will outline the Substance Abuse and Mental Health Services Administration recovery principles that guide professionals in developing ethical and evidence-based treatment programs. Finally, for the purpose of continuity of care and cooperation of care, I will explain the importance of ruling out other medical conditions and assessing the need for medications.

Before we create your treatment plan, several important steps are taken to ensure you are fully informed and engaged in the process. I will emphasize the importance of your active involvement in developing your treatment plan and monitoring your progress, as well as the requirement for you to sign the treatment plan and any revisions. Sometime before or after your intake appointment, you were sent several documents to review, complete, and sign. I encourage you to watch the videos on my YouTube channel, specifically the “About James Fitzgerald” playlist. These videos provide information about my educational background—including my bachelor’s degree in psychology and master’s degree in clinical mental health counseling—my training and work history, professional development and continuing education certificates, theoretical orientation, and integrative and holistic approaches to counseling.

Please review the intake process, compliance procedures, and instructions for completing the packet of intake documents. Please watch the instructional YouTube video that explains these processes in detail. I may have already asked you to review my professional public disclosure statement for Licensed Clinical Mental Health Counselors (LCMHCs) and sign an acknowledgment that you have reviewed the document. A new statement will be provided to you each year we work together. I may have already asked you to review the Vermont Secretary of State Office of Professional Regulation’s statutes and professional regulations document, which will also be updated annually. Optionally, you could watch a series of instructional YouTube videos about this disclosure statement.

I may have already asked you to review my philosophical and theoretical orientation document and sign an acknowledgment of your review. An optional informational YouTube video was provided to further explain my philosophical and theoretical orientation. I may have asked you to review my ethical compliance and accountability statement and sign an acknowledgment that you have reviewed the document. An optional informational YouTube video was available to provide additional details about my ethical compliance and accountability practices. If you have not already completed and signed the paperwork I just discussed, please be prepared to review and sign them. These steps are designed to ensure you are fully informed and comfortable with the therapeutic process, fostering a collaborative and transparent relationship between us.

Be patient with me while I provide a quick review of what I have shared so far. The intake process involves a consultation session, paperwork to complete before the next session, and an initial assessment phase of therapy where I gather essential information about your medical history, family dynamics, mental health history, relationships, current concerns, and your goals for therapy. This helps me create a personalized treatment plan tailored to your needs. You will then receive detailed information about me, the therapeutic approach we will use, and any necessary administrative details. This is also an opportunity for you to ask any questions and address any concerns you may have. I will walk you through my policies, procedures, and privacy practices. You will learn about appointment scheduling, payment methods, and communication protocols. This phase ensures that you are fully informed and comfortable with the logistics of your care. If you are seeing me primarily through telehealth, you will be informed that we can only meet if you are physically located in the state of Vermont.

You will be asked to complete a series of forms and questionnaires that provide me with a comprehensive understanding of your history and present situation. This information is crucial for developing an effective and personalized plan for your care. Engaging in lessons and activities between sessions is a vital part of your therapy process. These tasks are designed to reinforce the concepts discussed during your sessions, provide opportunities for practice and reflection, and accelerate your progress. Research has shown that clients who actively participate in between-session activities experience greater improvements and achieve their goals sooner and more effectively.

By completing the in between session assignments, you will enhance your understanding of key concepts. You will be able to apply new skills in real-world situations. You may want to reflect on your experiences and insights. I will ask you to monitor your progress so we can make necessary adjustments as needed. The assignments help you stay motivated and engaged in your journey. Remember, I am here to support you every step of the way. If you encounter any challenges or have questions about the lessons and activities, please do not hesitate to reach out. Your active participation is essential for your success, and I am committed to helping you achieve the best possible outcomes.

The Medical Records Chart Documents Process:

The process of completing all the necessary forms and documents should be completed before we begin cooperatively creating your treatment plan. You should have been asked to complete all the intake documents on or before the day of the last intake appointment and have completed or reviewed and signed them. The forms are Therapy Notes LLC default forms and automatically become part of your clinical chart and medical records.