SESSION LENGTH & PROFESSIONAL FEES: Unless otherwise noted below, all fees listed are per session.
Individual Counseling – Initial Session: $145; Follow-Up Sessions: $120
Couples Counseling – $135
Sessions begin and end on time. It is understandable that occasionally you may be late. If you are late for your session, please understand that the session will not be extended, nor will time be added to future sessions.
APPOINTMENTS AND CANCELLATIONS: Cancellations must be made at least 24 hours in advance. Your session time has been reserved exclusively for you. Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Canceling with less than 24 hours notice will result in you being charged the full session fee.
MISSED APPOINTMENTS: If you do not show up for a session, you will be charged the full session fee.
ONGOING CANCELLATIONS OR MULTIPLE NO-SHOWS: It is understandable that you may occasionally need to cancel or miss an appointment due to illness or emergency. However, your appointment time has been reserved especially for you. Frequent cancellations missed appointments, late payments, or non-payment could result in the need to discontinue your treatment.
BILLING AND PAYMENT POLICY: Professional fees may be paid via cash, credit card, or debit card and are due at the time of service. If you plan to pay by credit or debit card, please complete the Credit Card Information form. Your card information will be stored in our system. We charge patients on the day of their session. If you prefer to pay by cash, please bring the exact amount with you. We are unable to make change.
Private Pay Services / Out of Network Insurance Billed Services – Payment is due at the time of service.
Insurance Billed Services – Co-payments & deductibles are due at the time of service and will be charged to the credit or debit card on-file.
Insurance Participation – Our providers participate with different insurance plans. We make every attempt to schedule you with an in-network provider; however, we cannot guarantee that the provider you are scheduled with is active in your network. It is the patient’s responsibility to confirm that any/all providers with whom they are scheduled are participating in their insurance network. Patients will be responsible for charges incurred for services rendered by an out-of-network provider.
Insurance Benefits – Please be aware that mental health benefits are normally different from your medical benefits. The Counseling Center does not verify insurance benefits information until after your initial visit with our group. It is your responsibility to verify and familiarize yourself with your mental health benefits.
Changes to Insurance – It is your responsibility to make sure we have your most current insurance card on file. Sometimes insurance may change to a different insurance company, other times it may just be a simple change to your ID number. Anytime you receive a new card, please notify our office or you can upload a copy through our website.
Claims Submission – The Counseling Center will file all claims with your primary insurance company upon submission of proof of insurance.
Past Due Balances – Our office reserves the right to cancel or refuse services for patient accounts with past due balances. Patients will be unable to schedule appointments if they have 2 outstanding co-payments, an account balance of $100 or more, or if your account balance is greater than 30 days past due after insurance processing.
Statements – will be sent via email on the 10th of each month. You can also access your statements online via the Client Portal. Payment in full is due upon receipt of the statement.
Financial Responsibility – The patient/responsible party are responsible for all charges incurred with The Counseling Center.
Collections – Accounts in violation of our financial policy are subject to placement with a third-party collection agency. The patient will be responsible for reasonable attorney and collection fees.
OUT OF NETWORK BILLING POLICY
Private Pay Services/Out of Network Insurance Billed Services – The Counseling Center does not bill for out-of-network services and payment in full is due at the time of service. You may request a SuperBill at the time of service.
TELEPHONE ACCESSIBILITY: Providers are not often immediately available by telephone. Email is the quickest way to reach your provider. If you would like to speak on the phone, you may leave a message with the receptionist by calling (317) 754-0808. We will make every effort to return your call within 24 hours, except for weekends and holidays. Messages left on weekends and holidays will be returned the next business day.
In the event of a psychiatric emergency, please call 911 or go to the nearest emergency room or crisis center and ask to be evaluated by a mental health practitioner. If the situation is urgent, but not an emergency, you can call the office at (317) 754-0808 and ask to have the On-Call Therapist paged. The National Suicide Prevention Lifeline is also available 24 hours a day, 7 days a week at (800) 273-TALK (1-800-273-8255).
SOCIAL MEDIA AND TELECOMMUNICATION: Due to the importance of your confidentiality and the need to minimize dual relationships, we 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 choose to follow our business-related social media accounts, please know that this may be visible to others who view the sites.
ELECTRONIC COMMUNICATION: We cannot ensure the confidentiality of any form of communication through certain electronic media such as text messages. Therefore, except for scheduling and appointment reminders, the office will not use text messaging to communicate with you. Messages sent to you through the Client Portal or via email@example.com are HIPAA compliant forms of confidential communication.
Confidentiality: Our office utilizes and recommends exclusive use of SimplePractice, a confidential, HIPAA compliant audio/video conferencing application, for all telehealth appointments. The Counseling Center LLC is not responsible for breach of confidentiality when using any other telehealth platform including over the telephone or via email.
We ask that you be in a private, secure, location for your appointment to reduce the likelihood of your confidential health information being compromised.
You must be physically located in the State of Indiana to receive treatment via telehealth from any Counseling Center provider. It is unlawful for our providers to provide treatment across state lines unless they are dually licensed in the state that you are physically present in.
Coverage is determined by your insurance carrier. We highly encourage you to verify your telehealth benefits with your insurance company or your human resources representative.
I agree The Counseling Center LLC and its members, directors, partners, employees, and agents shall not be liable for any breach of confidentiality or privacy arising from teletherapy with me. I agree that I shall fully defend and hold The Counseling Center LLC harmless for principal, interest, court costs and reasonable attorneys’ fees, together with any judgment rendered against it because of or arising from this Request to Use, Informed Consent, and Agreement Regarding Use of Teletherapy.
I agree to waive all claims against or liability of and shall hold harmless The Counseling Center and its members, directors, partners, employees, and agents for any breach of confidentiality or privacy arising from teletherapy with me.
I agree I am signing this Informed Consent voluntarily and my signature is not the result of duress or undue influence.
I agree I have asked The Counseling Center all questions I had regarding this Informed Consent, and such questions were answered to my satisfaction.
I agree that this Request to Use, Informed Consent, and Agreement Regarding Use of Teletherapy represents the entire understanding regarding the subject matter herein. I agree that none of the terms of this Request to Use, Informed Consent, And Agreement Regarding Use of Teletherapy can be waived or modified, except by an express agreement signed by me and The Counseling Center LLC. I agree there are no representations, promises, warranties, covenants, or undertakings by The Counseling Center LLC other than those expressly set forth in this Agreement.
This Agreement is made and executed in the State of Indiana and shall be governed and always construed according to the laws of that state even though I may later reside or be domiciled outside of Indiana.
MINORS: If you are a minor, your parents may be legally entitled to some information about your therapy. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION: Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your counselor may terminate treatment after appropriate discussion with you, if he determines that the counseling is not being effectively used, or if you are in default on payment. Your counselor 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 counselor, your counselor will provide you with a list of qualified counselors to treat you. You may also choose someone on your own or from another referral source.
CONFIDENTIALITY: Your confidentiality as a client is of utmost importance. To secure your clinical information, we use an electronic health record to store and protect your information in a confidential and protected capacity. All client protected health information is covered under the Health Insurance and Portability Act of 1996 and 45 C.F.R., Part 164, Subpart C under HIPAA. As a therapy client, you have privileged communication. This means that your relationship with me as my client, all information disclosed in our sessions, and the written records of those sessions are confidential and may not be revealed to anyone without your written permission, except where law requires disclosure. Most of the provisions explaining when the law requires disclosure are described in the Notice of Privacy Practices.
When Disclosure Is Required by Law: Disclosure is required when there is a reasonable suspicion of child, dependent or elder abuse or neglect and when a client presents a danger to self, to others, to property, or is gravely disabled.
When Disclosure May Be Required: Disclosure may be required in a legal proceeding. If you place your mental status at issue in litigation that you initiate, the defendant may have the right to obtain your psychotherapy records and/or my testimony. If you have not paid your bill for treatment for a long period of time, your name, payment record and last known address may be sent to a collection agency or small claims court. In couples or relationship therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information.
Emergencies: If there is an emergency during our work together or after termination in which your provider becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving psychiatric care, the provider will do whatever they can, within the limits of the law, to prevent you from injuring yourself or another, and to ensure that you receive appropriate medical care. For this purpose, your provider may contact the person whose name you have provided as your emergency contact.
Health Insurance and Confidentiality of Records: Your health insurance carrier may require disclosure of confidential information to process claims. Only the minimum necessary information will be communicated to your insurance carrier, including diagnosis, the date and length of our appointments, and what services were provided. Often the billing statement and your company’s claim form are sufficient. Sometimes treatment summaries or progress toward goals are also required. Unless explicitly authorized by you, Psychotherapy Notes will not be disclosed to your insurance carrier. While insurance companies claim to keep this information confidential, I have no control over the information once it leaves my office. Please be aware that submitting a mental health invoice for reimbursement carries some risk to confidentiality, privacy, or future eligibility to obtain health or life insurance.
NON-DISCRIMINATION POLICY: The Counseling Center does not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. We are committed to providing an inclusive and welcoming environment for all clients and visitors.
PHYSICAL CONTACT: Sexual contact is never acceptable in the therapeutic relationship. Romantic or sexual conversation, flirting, or sexual innuendos and sexual jokes are also unacceptable. If you direct a sexual comment or joke toward your counselor while in session, they will explore the comment professionally and in a non-shaming way with the confines of a non-sexual therapeutic relationship.
REFERRAL OF FRIENDS, FAMILY, CO-WORKERS: The greatest compliment a counselor can receive is a referral from current or former clients. Please understand that your confidentiality is extremely important. Your counselor will never acknowledge you as a client to other clients, or to anyone outside of The Counseling Center without your written consent, or unless mandated by a court of law.
COURT REPORTS OR LETTERS: I do not write legal letters or court reports on behalf of clients involving divorce, custody, or lawsuits. I do not write letters pertaining to legal matters to any outside person (i.e. doctor, school, attorney, etc.) or agency regarding your treatment. If you are referred for a substance abuse assessment, the summary of that assessment, along with recommendations, will be sent to the referring agency. If a special circumstance arises where a letter is required, it will require your written consent and will be billed to you at $35.00 per page in addition to my hourly fee. I reserve the right to refuse to write letters on your behalf (unless court-mandated) if I do not feel this would be in your best interest, if it places us in a dual relationship, or it would compromise our therapeutic relationship. If you are involved in a lawsuit, please understand that entering your mental health into a court hearing may not always be in your best interest as it may compromise your confidentiality and your clinical files may be requested.
COURT FEES: If you become involved in legal proceedings that require my mandated participation, you will be expected to pay for all my professional time, including preparation and transportation time and costs, even if called to testify by another party. Because of the time involved and the interruption to my clinical work, you will be charged $250 per hour for time out of practice, time for preparation, travel time, and attendance at any legal proceeding on your behalf. Additionally, if other client sessions must be canceled, these must be covered at the rate of those sessions and will be billed to you.
ADDITIONAL RIGHTS AND RESPONSIBILITIES: In addition to your right to confidentiality, you have the right to end your counseling at any time, for whatever reason and without any obligation, except for payment of fees for services already provided. You have the right to question any aspect of your treatment with your counselor. You also have the right to expect that your counselor will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you.
The Counseling Center reserves the right to discontinue counseling services at any time and for any reason, including, but not limited to, a violation of these Practice Policies, a change or reevaluation by The Counseling Center of your therapeutic needs and The Counseling Center’s ability to address those needs, or other circumstances that lead The Counseling Center to conclude in its sole and absolute discretion that your counseling needs would be better served by another practitioner. Under such circumstances, The Counseling Center will suggest an appropriate counselor(s) or counseling agency.
I have read, or have had read to me, the information contained in this Notice, which is also available on The Counseling Center’s website at www.TCC-INDY.com. I have discussed the points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this Notice.
Effective Date: June 30, 2019
Last Revised: November 23, 2021
Last Reviewed: November 23, 2021
Next Review: November 23, 2022
Approved By: Jason Lynch, Owner/CEO