Thank you for sharing information about yourself. It takes courage to reach out for help and I’m glad you did. I am Chris Perkins, a Licensed Clinical Professional Counselor (LCPC) in Illinois. You can read more about my background, education, experience, and counseling approach. I am so glad that you’ve taken the steps to reach out for help with whatever situation in your life has become unmanageable right now. I hope that my areas of expertise will be good fit to address those parts of your life and help you reach your goals. Your well-being is my number one priority. BetterHelp does not provide me with your personal or billing information that you provided when you signed up for your subscription. In order for me to maintain compliance with my licensing board and ethical code and to ensure your safety and well-being, I am required to gather some basic personal information. Please COPY/PASTE the following questions into a message back to me: Full Name: Date of Birth: Home Address: Phone Number: Emergency Contact Name: Emergency Contact Relation to You: Emergency Contact Phone Number: Have You Had Prior Mental Health Treatment? If So, where? For What Condition? Are you Prescribed Any Medication? Who is the Prescribing Physician? Have you Ever Been Hospitalized for Mental Health Treatment? If So, Where and When? Which Substances do you use if any? (ex. Alcohol, Marijuana, Cocaine/Stimulants, >Heroin/Opiates, Xanax/Benzodiazepines, Inhalants/Paint/Glue/Gas/Huffing) How often do you use substances? Have you ever experienced psychosis (hallucinations – seeing or hearing things that others do not see or hear)? How often does that occur? Have you ever wished that you were dead or would not wake up? Have you ever had thoughts of harming or killing yourself? Have you ever considered or researched methods of suicide or self-harm? Have you ever had these thoughts and had some intentions of acting on them (as opposed to thinking about suicide but knowing you would never intend to do so)? Have you ever made a plan to harm or kill yourself? If so, when and what was the plan? Do you agree to contact 911 or go to your local emergency room if you should feel urges to harm or kill yourself? Once you have sent this information back to me we can discuss next steps. I look forward to working with you! My Member Information Form Template says: I have read, understand, and agree to the Client Terms of Service at Our Client Terms & Conditions | BetterHelp . It is my sole responsibility to review these terms of service and understand how they affect my use of this platform. I understand that upon assessment and evaluation, Chris Perkins, LCPC, will determine whether he is able to provide the level or type of care that I require. In the instance that his areas of expertise do not align with the type or level of care I require, he will provide me with assistance and referrals to connect to an appropriate treatment provider. Chris Perkins, LCPC, endeavors to provide a Good Faith Estimate of costs of care. I understand that due to the nature of mental health treatment it is not possible to determine an exact length of treatment. However, Chris Perkins, LCPC, will review progress with me periodically and together we will determine ongoing treatment plans. All pricing, rates and billing questions should be directed to customer service at [email protected]. I understand that the BetterHelp Platform is intended for INDIVIDUAL ADULTS aged 18+ who are consenting to treatment via telehealth services. I understand that should I be seeking services for my adolescent child (aged 13-17), that I will utilize BetterHelp’s partner platform, TeenCounseling. I understand that should I be seeking Couple’s Counseling, I will utilize BetterHelp’s partner platform ReGain. I understand that the service provided through BetterHelp is NOT INTENDED FOR CRISIS SITUATIONS OR URGENT NEEDS. In a crisis situation, I agree to call 911 or local emergency services, or visit the nearest emergency room. I understand that at the beginning of our treatment relationship, Chris Perkins, LCPC will request my contact information and the contact information of an emergency contact individual whom I can designate. This designation does NOT allow Chris Perkins, LCPC to release information to the individual, excepting in instances of emergent and imminent danger to myself or someone else (i.e. active suicidal ideation/actions, active plan to harm someone else). I also understand that should there be an instance of emergent or imminent danger to myself or someone else as described, Chris Perkins, LCPC is mandated by the State of Illinois licensing regulations to report this to the local authorities in order for them to intervene for my safety or the safety of others. I understand that information shared with Chris Perkins, LCPC is confidential except in the following circumstances: If I present as a danger to myself or others, mandated reporting of abuse of children or elders, or if I sign a release of information. I understand that Chris Perkins, LCPC offers the following types of sessions: texting (which are important for some as stand-alone sessions or with “live” sessions); and “live” sessions. I understand that Chris Perkins, LCPC offers the following types of live sessions: live video (video call where client and therapist can see each other in real time), live phone (phone call through the BetterHelp app where only audio is used), or live chat (a “real time” chat window where client and therapist have dedicated time to have discussion via typing). I understand that Chris Perkins, LCPC offers sessions Monday through Friday during from the hours of 9:00am to 4pm (last session begins at 3:15) and offers messaging in between sessions should I need additional support. I understand that Chris Perkins, LCPC offers sessions of 45-minute duration. I understand that Chris Perkins, LCPC can offer multiple sessions per week should this level of care be clinically necessary for my treatment. I understand that to have more than one session in a week may result in my incurring additional charges on my BetterHelp subscription. Any questions regarding these fees or other billing related matters should be directed to [email protected] I understand that Chris Perkins, LCPC. is not “on-call” and may take up to 24 business hours (1 business day) to reply to my messages. This means that if I message Chris Perkins, LCPC on a Friday evening, I may not receive a response until Monday morning. I understand that Chris Perkins, LCPC encourages at least 24-hour notice of appointment cancellation. Should I need to cancel an appointment, I will inform Chris Perkins, LCPC at my earliest convenience. Should I need to cancel with fewer than 24 hours left before my appointment, the cancellation will be reported as a “no-show/late cancellation” and I will receive an auto generated alert email from BetterHelp indicating this. I understand that Chris Perkins, LCPC will wait 15 minutes after my scheduled appointment start time to start; however, if I have not come online by that time, Chris Perkins, LCPC will consider me a no-show and the session will need to be rescheduled. I understand that should I have 2 late cancellations/no-shows within a month, Chris Perkins, LCPC may not be able to continue to accommodate my preferred session times and dates. Should I have 3 late cancellations/no-shows within a 6 week span, Chris Perkins, LCPC may recommend that I seek in person treatment and/or switch therapists on the BetterHelp Platform. I understand that my sessions should be conducted in a place where I have privacy, am away from all distractions, am NOT DRIVING or engaging in other activities that require my attention and focus. Chris Perkins, LCPC is understanding of the occasional “pet appearance” during session. I understand that I can invite others to be a part of my treatment (and am encouraged to do so) as support people. However, should I invite a support person to be involved in a session, Chris Perkins, LCPC will require me to sign a release of Information for that individual. I understand that the BetterHelp platform is not intended for Couples Counseling, and if that is the service I am seeking, I will utilize BetterHelp’s partner site ReGain. I understand that the BetterHelp Platform is not intended for the purposes of diagnosing, prescribing medication, or other services that would, by state licensing regulations, require an in-person evaluation. This means that any documentation such as court paperwork, ESA Letters, FMLA Paperwork, Insurance Paperwork, etc. may not be able to be accommodated as these frequently require diagnostic information. I agree to discuss these things with Chris Perkins, LCPC, should the need arise and acknowledge that these situations will be handled on a case-by-case basis dependent on the circumstances. I understand that if I am in crisis where I am feeling like hurting myself or hurting someone else, BetterHelp is truly not the best venue or platform to address these crisis feelings. I understand that Better help recommends that if I am in immediate crisis that I call 911 or 1-800-273-TALK (8255) to speak to someone right away.