Practice Policy
Folx and Friends Counseling L.L.C.
6061 Stoney Creek Drive
Fort Wayne, IN 46825
tel: (260) 600 9546
fax: (260 ) 234 2821
Folx and Friends Counseling LLC is a privately owned and operated business, that strives to
offer quality and affordable technology-enabled and in-person mental health services. We
believe strongly that the foundation for quality therapy, is the therapeutic relationship between
the therapist and client. Our goal is to ensure that the time that you spend in therapy is truly
your time, feels beneficial for you, and something that you see as a benefit. This Agreement
describes Folx and Friends Counseling services and clinical programs. It is important for you to
read this document and discuss any questions you might have with us. If you agree to these
terms, we will assume that you have read, understood, and agree to its contents. We reserve
the right, at our sole discretion, to change, modify, add or remove portions of these terms, at
any time. We will provide notice of any changes, through sending secure notification in
SimplePractice. It is your responsibility to check these terms periodically for changes.
INFORMED CONSENT FOR PSYCHOTHERAPY
GENERAL INFORMATION
The therapeutic relationship is unique in that it is a highly personal and at the same time, a
contractual agreement. Given this, it is important for us to reach a clear understanding about
how our relationship will work, and what each of us can expect. This consent will provide a
clear framework for our work together. Feel free to discuss any of this with me. Please read and
indicate that you have reviewed this information and agree to it by filling in the checkbox at the
end of this document.
THE THERAPEUTIC PROCESS
You have taken a very positive step by deciding to seek therapy. The outcome of your
treatment depends largely on your willingness to engage in this process, which may, at times,
result in considerable discomfort. Remembering unpleasant events and becoming aware of
feelings attached to those events can bring on strong feelings of anger, depression, anxiety,
etc. There are no miracle cures. I cannot promise that your behavior or circumstance will
change. I can promise to support you and do my very best to understand you and repeating
patterns, as well as to help you clarify what it is that you want for yourself.
TELEHEALTH & TECHNOLOGY SERVICES
When you or your child becomes a client of Folx and Friends Counseling, you will be given
access to the mobile or desktop application of SimplePractice. SimplePractice is a electronic
health record and technology platform that Folx and Friends Counseling contracts with to
provide safe and secure delivery of telehealth services, billing, and therapeutic documentation.
The SimplePractice client portal provides personalized content and interactive resources for
you, simple tools for scheduling appointments, contacting your therapist, and billing, serves as
your hub of information including medical records. You may use the SimpePractice client portal
so long as you are over the age of 18 or other legal age of consent and meet any additional
criteria under applicable state law, and/or have the necessary capacity or authority to enter
binding agreements like this through a consenting parent or legal guardian, as explained below.
If you access or use the SimplePratice client portal, it will mean you read, understood and
expressly agree to these Terms and that you will use the services only in accordance with the
terms and conditions herein and all other applicable agreements, information, services,
materials and other content provided by or through Folx and Friends Counseling. Your
continued use of the SimplePractice client portal following the posting of changes will mean
that you accept and agree to the changes.
Mental health services can be furnished using a number of different modalities, including
telehealth, which allows you to seek care services using a secure audio or visual technology
platform, rather than requiring you to come into an office for face-to-face appointments.
Telehealth services are provided synchronously, meaning you and your provider will
communicate in real time during a scheduled appointment over an audio/visual technology
platform. There are many benefits to telehealth services, such as easier and more convenient
access to services and receiving services from the comfort and safety of your home or
workplace. However, there are also risks associated with telehealth services, including, but not
limited to, technological failures, delays in response, and the limitations of therapy via
electronic means. This section is intended to inform you of these risks, as well as the benefits,
so that you may make an informed decision on whether or not to use telehealth services.
You understand that, in connection with telehealth services, your provider will be located at a
remote location and will not be physically present with you. Your provider will communicate
with you during scheduled telehealth appointments. Simple Practice has a secure platform that
your provider can use to communicate with you via video, audio, or messaging
communications. However, there always is a possibility that the transmission of your
information could be disrupted or distorted by technical failures, or could be interrupted by
unauthorized persons.
To increase security, we recommend that you avoid using public access computers or shared
networks. Telehealth has the same purpose or intention as psychotherapy, psychological
treatment, and other mental health or counseling treatment that are conducted in person.
However, due to the nature of the technology used, you may experience telehealth somewhat
differently than face-to-face treatment appointments. Therefore, your provider will continuously
assess whether telehealth is appropriate for your specific treatment needs. It is important that
you establish a plan with your provider in case you experience technological difficulties and get
disconnected, or you experience a mental health crisis requiring in-person treatment.
If you and your therapist chose to use information technology for some or all of your
treatment, you need to understand that:
1. You retain the option to withhold or withdraw consent at any time without affecting the right
to future care or treatment or risking the loss or withdrawal of any program benefits to which
you would otherwise be entitled.
2. All existing confidentiality protections are equally applicable.
3. Your access to all health information transmitted during a teletherapy consultation is
guaranteed, and copies of this information are available for a reasonable fee.
4. Dissemination of any of your identifiable images or information from the telemedicine
interaction to researchers or other entities shall not occur without your consent.
5. There are potential risks, consequences, and benefits of telemedicine. Potential benefits
include, but are not limited to improved communication capabilities, providing convenient
access to up-to-date information, consultations, support, reduced costs, improved quality,
change in the conditions of practice, improved access to therapy, better continuity of care,
and reduction of lost work time and travel cost.
BACK UP OPTIONS DURING A VIRTUAL SESSION
● If you get disconnected due to technological difficulties, we will contact you using the
information you provided to us at intake. If you get disconnected during a mental health
crisis, we will contact you, or if we are unable to reach you, your emergency contact. It is
imperative that you ensure your, or your emergency contact’s, information is always
up-to-date.
● If you are experiencing an emergency situation, you must call 911 or proceed to the nearest
hospital emergency room for help. If you are having suicidal thoughts or making plans to
harm yourself, you can call or text the National Crisis & Suicide Lifeline at 988 for free
24-hour hotline support
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual
relationships, our clinicians do not accept friend or contact requests from current or former
clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients
as friends or contacts on these sites can compromise your confidentiality and our respective
privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions
about this, please bring them up when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION (TEXT MESSAGE & EMAIL)
We cannot ensure the confidentiality of any form of communication through electronic media,
including text messages, except for communication done through the SimplePractice client
portal. The SimplePractice client portal is the preferred method of communication between you
and your clinician at Folx and Friends Counseling.
If you prefer to communicate via email or text messaging for issues regarding scheduling or
cancellations, let us know. While we may try to return messages in a timely manner, we cannot
guarantee immediate response and request that you do not use these methods of
communication to discuss therapeutic content and/or request assistance for emergencies.
We use a business phone system called OPENPHONE, which enables all our support staff to
monitor messages, during business hours, to assist in responding to any requests (e.g.
scheduling, billing, cancelation or other identified needs requested by you).
GUARDIANS CONSENT ON BEHALF OF MINOR CHILDREN
Authorization for Minor’s Behavioral Health Services In order to authorize behavioral health
services for your child, you must have either sole or joint legal custody of your child. If you are
separated or divorced (or become separated or divorced) from the other parent of your child,
you agree to immediately notify the other parent that a provider at Folx and Friends Counseling
is meeting with your child.
You are responsible for ensuring that Folx and Friends Counseling has the appropriate
authorizations needed for the treatment of your child. We may require you to provide, where
custody or the right to information about treatment is contested, a copy of the most recent
custody decree or other documentation that establishes custody rights of you and the other
parent or otherwise demonstrates that you have the right to authorize treatment for your child.
If there are any changes in the status of legal guardianship/parent status, you understand that it
is your responsibility to promptly notify us of any such changes.
One risk of child therapy involves disagreement among parents and/or disagreement between
parents and the child’s therapist or clinician regarding the child’s treatment. If either parent with
the appropriate authority decides that behavioral health services should end, Folx and Friends
Counseling will honor that decision, unless there are extraordinary circumstances.
However, in most cases, we will ask that you allow us the option of having a few closing
appointments with your child to appropriately end the treatment relationship. During the
treatment of a child, our providers may meet with the child’s parents/guardians either
separately or together. Please be aware that our patient is the child - not the parents/guardians
nor any siblings or other family members of the child.
Furthermore, any communication by a parent to our providers may be legally disclosed to the
other parent, unless that parent’s parental rights have been removed. A parent should NOT
share any information which they are not willing to have disclosed to the other parent. You
hereby certify that you have legal authority to authorize providers at Folx and Friends
Counseling to provide behavioral health services to your child. You further certify that, if you are
a party to or otherwise the subject of any agreement or court order that requires the written
approval of the child’s other parent or any third party to authorize behavioral health services for
your child, you have provided or will provide that written approval prior to or at the start of
treatment.
IMPORTANT INFORMATION FOR PARENTS, CAREGIVERS & CONSENTING ON BEHALF
OF MINOR CHILDREN:
Your participation is important, and is often essential to the success of the treatment. This
section is intended to inform you about the risks, rights and responsibilities of your
participation as a collateral participant. Your agreement and signature, below, indicates your
understanding of your role as a collateral and the limitations therein. If you have any questions
or concerns about what it means to be a collateral, and especially if you have questions or
concerns about information that may be shared with another parent, it is critical that you
discuss these questions/concerns with your clinician.
WHO AND WHAT IS A COLLATERAL?
A collateral is usually a parent or caretaker who participates in therapy to assist the child. The
collateral is not considered to be a patient and is not the subject of the treatment. In addition to
the mental health clinician’s primary responsibility being to the patient with respect to
treatment, they also have certain legal and ethical responsibilities to patients, and the privacy
of that relationship is given legal protection. That privacy protection does not apply to
collaterals.
THE ROLE OF COLLATERALS IN THERAPY
The role of a collateral can vary greatly. For example, a collateral might attend only one
appointment, either alone or with the patient, to provide information to the clinician and never
attend another appointment. In another case a collateral might attend all of the patient’s
therapy appointments and their relationship with the patient may be a focus of the treatment.
Your child’s clinician will discuss your specific role in the treatment at your first meeting and at
other appropriate times.
BENEFITS AND RISK
Mental health treatment can engender intense emotional experiences, and your participation in
your child’s treatment may also cause strong anxiety or emotional distress. It may also expose
or create tension in your relationship with your child. While your participation can result in
better understanding of your child or an improved relationship, or may even help in your own
growth and development, there is no guarantee that this will be the case. If you are
participating in your child’s treatment, you should expect the clinician to request that you
examine your own attitudes and behaviors to determine if you can make positive changes that
will be of benefit to your child.
PROFESSIONAL RECORDS
No separate medical record or chart will be maintained on you in your role as a collateral.
However, your demographic information will be maintained as part of your child’s record, and
information you provide may be entered into your child’s chart, if appropriate. Your child and
other adults with a right of access to health records may have a right to access the chart and
the material contained therein, which may include information and communications you have
provided. Other adults with a right of access to the chart / record may also have access to the
information / communications you provide. There will not be a diagnosis assigned to you in
your role as a collateral and there is no individualized treatment plan for you.
THE CONFIDENTIALITY OF THE THINGS YOU SAY TO YOUR CHILD’S CARE TIME
The confidentiality of information in your child’s chart, including the information that you
provide, is protected by both federal and state law. However, as a collateral you are not the
patient, but rather you are assisting in the clinical care of a child and are not directly receiving
treatment yourself. Clinicians specializing in the treatment of children have long recognized the
need to treat children in the context of their family. In treatment involving children and their
parents, access to information is an important and sometimes contentious topic. Particularly
for older children, trust and privacy are crucial to treatment success. But parents also need to
know certain information about the treatment. For this reason, your child’s clinician may elect
to discuss what information will be shared and what information will remain private, in
accordance with applicable state law.
CONFIDENTIALITY
The session content and all relevant materials to the client’s treatment will be held confidential
unless the client requests in writing to have all or portions of such content released to a
specifically named person/persons. Limitations of such client held privilege of confidentiality
exist and are itemized below:
1. If a client threatens or attempts to commit suicide or otherwise conducts themselves in a
manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the
perpetrator, observer of, or actual victim of physical, neglect, emotional or sexual abuse of
children under the age of 18 years.
4. Suspicions as stated above in the case of an at risk adult (person 18 and older) person who
may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is
obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally, we may need to consult with other professionals in their areas of expertise in
order to provide the best treatment for you. Information about you may be shared in this
context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first.
Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to
jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to
speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public
or outside of the therapy office.
FINANCIAL INFORMATION
You have received information on the fees that you will incur for services. You understand that
you are financially responsible for charges that are not covered or paid by your insurance. You
hereby consent to the release of information to third-party payors or their representatives as
deemed necessary by Folx and Friends Counseling to determine benefits entitlement and to
process payment claims for services provided.
You authorize and direct that payment of any health insurance or healthcare benefits otherwise
payable to you for health care services will be paid directly to Folx and Friends Counseling for
the charges for which Folx and Friends Counseling is authorized to bill in connection with the
services provided to you.
You certify that the information given by you in applying for payment is correct. You
acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your
insurance company or other payor. Charges are due and payable upon receipt of the bill.
If you have questions, you are encouraged and expected to ask them before you acknowledge
this form. Your acknowledgement of this form indicates that you have read and understand this
document and that you have had the opportunity to ask questions about anything in this form.
SCHEDULING & ATTENDANCE
Please remember to cancel or reschedule 24 hours in advance. You may be responsible for a
cancellation fee of $50 if cancellation is same day, with notice by Folx and Friends Counseling
L.L.C. If you are unable to attend your session, proactive efforts to communicate with your
provider is important.
MISSED APPOINTMENTS & SAME DAY CANCELLATIONS
The standard meeting time for psychotherapy is 53 to 55 minutes. It is up to you, however, to
determine the length of time of your sessions. Requests to change the 53-minute session
needs to be discussed with the therapist in order for time to be scheduled in advance.
● Individuals who do not show for their appointment and make no efforts to communicate or
reschedule will be
● charged $75
● within 24 to 48 hours of missed appointment.
● Same day cancellations are subject to a $50 charge, with notice by Folx and Friends
Counseling L.L.C.
MISSED/NO-SHOW APPOINTMENTS
We understand sometimes there are emergency or moments of forgetfulness leading to a
no-show appointment, which is defined as an individual who did not proactively communicate
with therapist or support staff prior to the start of the scheduled appointment. We will waive
one time, a missed/no-show appointment. We will communicate via SimplePractice Secure
Portal the missed appointment, the waived $75 fee, and remind you of the fee being assessed
moving forward.
SAME DAY CANCELLATION
We recognize changes or unexpected events can occur, we are committed to flexibility.
Individuals who are proactive in communicating with their therapist to cancel or reschedule
their appointment can have this fee waived. Individuals building a habit of cancellations are
subject to this $50 same-day cancellation. Prior to this charge, your therapist will communicate
this with you.
While we recognize a variety of life circumstances can happen, the time schedule is held
exclusively for you. Preventing any other individual from securing this time and having a
disruption in anticipated business priorities. Your therapist will wait 15 minutes for you to arrive
for your session in-person or via teletherapy. After 15 minutes your session is considered
missed and the missed appointment fee applies. If you arrive within the 15 minute grace period
your session will still end at the regularly scheduled time.
ADDITIONAL FEES
COURT FEES
There are a variety of reasons clients or their attorney, on behalf of a client to participate in
court proceedings through use of subpoenas or summons. We will, determined by counsel,
provide a response to any subpoena or court summons. We will, determined by counsel,
communicate directly with you. In situations involving custodial matters of children, it is
important to understand we do not provide professional opinions on specific custodial matters.
We speak to the direct services provided to the client, often the specific child of the custodial
matter.
Day Rate:
$1200
Administrative Cost:
$600
Travel, Parking, & Food (Allen County)
: $50 (includes drive time)
Travel, Parking, & Food (Out of county):
Mileage at standard federal rate of reimbursement, plus drive time at a rate of $50 an hour,
plus parking estimated at $20, and food estimated at $20. *** To be estimated upon notification
of court appearance ***
Upon notification or receipt of a subpoena, we will send an itemized invoice for anticipatory
services based on the above schedule of fees.
You have a 72 hour window to rescind the decision to subpoena your therapist. Due to the
nature of therapy and to ensure our ability to attend said court hearing, we will be canceling all
appointments the day of the hearing. After 72 hours, we will begin to cancel appointments and
block out administrative time to ensure preparedness for your court hearing you have
requested our attendance.
After 72 hours, if we have not received court orders or correspondence from an attorney to
release us from said court hearing, our schedule of fees will apply and we will pursue collection
effort. This is due to having already impacted other individuals' appointments.
TERMINATION/TRANSFER OF SERVICES
Ending relationships can be difficult. Therefore, it is important to have a termination process in
order to achieve some closure. The appropriate length of the termination depends on the
length and intensity of the treatment.
It is always recommended that you consistently communicate with your clinician how sessions
are going and if you feel like you may need to discontinue therapy or would like a referral
elsewhere. Though it can feel awkward, having honest conversation if you feel you would like to
terminate therapy is important so that we can appropriately end services and can ensure that
you are safe and have the supports you need.
A clinician at Folx and Friends Counseling may terminate or transfer treatment after appropriate
discussion with you and a termination process if it is determined that the psychotherapy is not
being effectively used, you require treatment beyond the scope/expertise of the rendering
provider, or if you are in default on payment.
We will not terminate the therapeutic relationship without first discussing and exploring the
reasons and purpose of terminating. If therapy is terminated for any reason or you request
another therapist, we will provide you with contact information of qualified psychotherapists to
treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for four consecutive weeks, unless other
arrangements have been made in advance, for legal and ethical reasons, we must consider the
professional relationship discontinued.
By acknowledging this Informed Consent, you confirm and agree to the following:
● You have been informed and have had an opportunity to ask questions and receive answers
about the potential risks, limitations, alternatives, and benefits of receiving services, whether
in-person or through telehealth and, after considering such matters, you consent to
receiving telehealth services if such modality is appropriate and desired.
● No promises or guarantees have been made to me regarding the therapy services that you
will receive.
● You have provided, or will provide before treatment, Folx and Friends Counseling accurate
information regarding your identity and location.
● You have received information about the identity, practice location, and other information
regarding your provider.
● You have been informed regarding how to enter appointments and communicate with your
provider via Folx and Friends Counseling telehealth platform (Simple Practice), and will
discuss a plan with your provider for how to work around technological difficulties and
connections issues should they occur.
● If your provider determines that telehealth services are not appropriate for your condition or
care, your provider may use other appropriate arrangements, including a referral or
scheduling in-person services.
● You may refuse telehealth and/or medication management services at any time, without loss
or withdrawal of treatment options or affecting your right to future treatment.
● All applicable confidentiality protections apply to our services, in accordance with the
Notice of Privacy Practices also provided to you.