Dr. Robin Perry Braun

Dr. Robin Perry Braun, PhD, IMD, CILPP

2412 Willow Way

Round Rock, TX 78664

386-212-5221

integratedlifestrategies@gmail.com

drobinbraun.com

 

 

INFORMATION AND CONSENT STATEMENT

 

This document contains important information about the counseling services that will be provided to you as a client.  Please read all the information carefully and ask any questions you may have about the content of this document.  It is my full intent to provide the best possible counseling services to meet your particular and individualized need.  Upon signing this consent form, it will constitute an agreement between you and your counselor.

 

EDUCATION:

 

            University of Dallas, Irving, TX, MPsy

            University of Dallas, Irving, TX BAPsych

            Int’l Quantum University Integrated Medicine, Hawaii, PhD, IMD

 

 

CERTIFICATION:

 

            Incomplete Licensed Professional Counselor in the State of Texas (conflict with

            Energy work)

            Former Chemical Dependency Counselor intern in State of Texas

            Certified Addiction Professional training in Florida

            Ordained Minister, Vision Life Ministries, TX, Patria Ministries, AL

            Certified Emotion Code Practitioner

            Integrated Life Process Practitioner

            Elijah House Certified

            Restoring the Foundations Certified

            Vision Life Ministries Certified

            Exchanged Life Certified

 

INTENT AND NATURE OF COUNSELING

 

                You have the right to choose alternatives and to participate in designing your treatment plan. My guidelines for creating a  plan incorporate an approach to counseling which takes into account the spiritual, psychological, social and biological dimensions of a person. I am also an energy practitioner and use muscle testing to find causes of imbalances within your body, soul or spirit.  I will use whatever tools seem to best apply to the situation as needed.

 

INTEGRATED LIFE PROCESS PRACTITIONER AND PRAYER MINISTRY

The legal guidelines for Energy Practice and Prayer Ministry are different from counseling. In traditional counseling, the transference relationship between client and practitioner is part of the process.  In energy methods this is not so.  In Prayer Ministry this is not so.  I will use my discernment and professional opinion to determine which tools are best for each client.

 

FAMILY

My goals in Family therapy relate primarily to personal responsibility for emotions and behaviors and creating a positive family atmosphere.  I use education, activities and homework to help create changes and give tools to make change possible and successful.  The outcomes will be dependent on the willingness of the family as a unit to apply the tools.  I will use more behavior and cognitive structuring than psychotherapy in this setting.   There may be times when you feel uncomfortable (certain feelings of sadness, guilt, shame, anger, anxiety, etc.).  When dealing with trauma, deep hurts, or issues/crisis you may also experience unpleasant feelings.  It is my intent to bring emotional healing as quickly as possible for you, but at the same time being sensitive and cognizant of what you are experiencing at the moment.  I will attempt to counsel you at a pace that is most effective for you.  You will experience release, freedom and a sense of well being as I begin to help you with the issues/desires that brought you here to begin with.

 

            Mutual respect is expected in these sessions.  I will respect your rights to thoughts and feelings but still expect homework and assignments to be carried out in spite of these feelings.  I intend for all interaction to be therapeutic in some manner.

 

            You will learn a great deal about me personally as we work together during your counseling experience; however, it is important for you to remember that you are experiencing me largely in my professional role.

 

INDIVIDUAL SESSIONS

            While much of my time is focused on energy work, the counseling part of this time may involve sharing of deep emotions and feelings and it is my intent to create as safe of an environment as possible.  The process does not require a reliving of these emotions however.

 

            I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards. You are entitled to an explanation of your condition and the treatment that will be provided as well as the duration and adverse risks involved. Please note that it is impossible to guarantee any specific results regarding your counseling goals; however, together we will work to achieve the best possible results for you.

 

 

CONFIDENTIALITY:

 

            The information which you tell me belongs to you, not to me; therefore, I will keep confidential anything you say to me with the following exceptions: (a) you direct me, in writing, to tell someone else; (b) I determine you are a danger to yourself or others; (c) I am ordered by a court to disclose information; (d) for supervision/consultation purposes; or (e) for backup coverage when I am not available. Please note that I am bound by my Ethical Code to contact the nearest of kin and /or proper authorities if, in my opinion, a person is deemed to be a threat to himself or to others. I am required, by law, to report incidences of physical or sexual abuse of a minor or of the elderly.

 

            This office may use and disclose medical information and financial information related to your care that may be necessary now or in the future to facilitate payment of third parties for services rendered to me. Guidelines for such disclosures will comply with the Health Insurance Privacy Practices Act. I am legally obligated to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices and to abide by its terms.

 

            It will be necessary for you to sign consent for release of information in the event you want any information released to another individual.

 

            In Energy practice, I will occasionally share an example from your session without naming you as an example for testimony or teaching purposes.  If you object to any part of your session being used even as an example, please let me know.  Because energy work is newer in scope but potentially very effective, I feel called to share testimonies from clients as showing the efficacy of the technique itself.  Your cooperation may help someone else but be assured names are never included in this practice.

 

 

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REFERRAL POLICY:

 

                The process of helping you address specific areas of your life is unique. It inevitably is the catalyst for several personal issues to arise that may cause some discomfort. This is a normal and natural part of the relational process occurring between

us. As the person chosen by you to be involved in this process, I will help you work through this discomfort. To this end I anticipate and desire a productive professional relationship with you.

 

            If I believe that I do not have sufficient training or expertise to appropriately guide your treatment, I will refer you to someone who can.

 

            In the event that a particular dissatisfaction with my services should arise, I am willing to discuss the nature of your dissatisfaction and make an attempt to move toward a solution acceptable to both of us. If we are unable to arrive at an acceptable solution, I will provide you with several possible referral sources.

 

FINANCIAL POLICY AND FEE ARRANGEMENTS:

 

            My fees are based on a sliding scale which is attached.  Session length is typically 1.5 hrs for first session ( or more) and 1 or more hours after that for subsequent sessions.   Length of treatment will be suggested according to issues and facility of progress.  There is no set amount of time.   

 

 I agree to provide counseling services for you. The fee for each session will be due and must be paid at the conclusion of each session unless otherwise arranged. I accept venmo, paypal, zelle, CC, cash app or cash when in person.

 

 

 

CANCELLATION POLICY:

 

            In the event that you will not be able to keep an appointment, you must notify me 24 hours in advance. If I receive less than 24 hours advance notice of cancellation of a scheduled session, you will be obligated to pay a sum of money equal to one half the amount for the session you missed. If you fail to show up for the appointment and no advance notice is given, you will be responsible for paying the full fee for the session that you missed unless previously discussed and oked.

 

RECORDKEEPING PROCEDURES:

 

            It is a requirement by law and the standards of the counseling profession that records are kept.  As the client, you have the right to your records, and a copy of which will be given to you upon your request.  The therapist may choose to give you just a summary of the sessions.  If you desire to see or listen to your records, it is best that you do so with your therapist present so that any questions that arise can be answered then.  Remember, this can be a very emotional experience for you and I desire to make this transition in your life go as smooth as possible.  If you are younger than 18 years old, the law requires that parents have the right to your records upon their request.  However, at the consent of the parent I would ask that information discussed with your child in sessions be kept confidential between your child and counselor, as this seems to enhance the counseling effectiveness for children.  The exception to this is if I foresee that your child is a danger to self or others then you will be informed, or in cases of sexual abuse.  General information will only be given to parents in the instance that they agree to this arrangement.  All work done with minors will only be done with the consent of a parent or legal guardian.

 

Disclaimer

I am an educator and I am not licensed to prescribe or change medication or make any claims to treat or eliminate any disease or illness.  All supplements recommended fall under the following disclaimer.

 

†These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. Use only as directed. Consult your healthcare provider before using supplements or providing supplements to children under the age of 18. The information provided herein is intended for your general knowledge only and is not intended to be, nor is it, medical advice or a substitute for medical advice. If you have or suspect you have, a specific medical condition or disease, please consult your healthcare provider.

 

 

If you have any questions, feel free to ask. Please sign and date this form to indicate that you have read, understand and consent to the information contained in it.

 

 

___________________________________              _____________________________

Dr. Robin Perry Braun, IMD, MPsy,                          Client’s signature

 

 

Date_______________________________              Date_________________________              

 

 

 

When making first appt - securing appt implies you have read and agreed to the informed consent.