Good Faith Estimate
You are entitled to receive this Estimate of your potential charges for therapy services provided to you.
While it is not possible for a therapist to know, in advance, how many therapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided.
Your total cost of services will depend upon the number of therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
This estimate is valid for 12 months. This estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of therapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
Fees
The fee for a 45-minute therapy visit (in person or via telehealth) is $175. The fee for a 60-75 minute first intake visit (in person or via telehealth) is $175. Most clients will attend one intake session and then one therapy visit per week, but the frequency of therapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs or desires.
You are responsible for payment of the agreed upon fee at the time of service and for any mental health services longer than 15 minutes on a pro rata basis. Therefore, there are no surprises about your fee or the cost of services. If you are confused about your fee, it is your responsibility to speak with me immediately to answer any questions you may have about these fees.
Frequency of Treatment
“Every client’s therapy journey is unique. How long you need to engage in therapy and how often you attend session will be influenced by many factors. ”
Your availability.
My availability.
Any vacations, holidays, emergencies, inclement weather, and sick time that you or I may experience.
The nature of your mental health and symptoms/behaviors.
Your process in treatment.
Reduction of your mental health symptoms/behaviors.
Your personal finances and commitment to the therapeutic process.
Your intention or goal of therapy (e.g., process/get to the root of issues, talk and have a sounding board).
I will continually assess your/your child’s mental health needs and will make recommendations about frequency of sessions and length of treatment according to your need and ongoing progress towards your treatment goals. Please reach out to me at any point to request a change in frequency or to discuss your treatment frequency and goals. We will create a treatment plan together and it will be available to view on your client portal.
Type of Treatment & Cost of Treatment
Below is a list of potential mental health treatment services that you can reasonably expect may be offered to you during the course of treatment AND based on the above-mentioned factors:
Individual Therapy Session, 45 minutes, at $175 per session.
Late cancellation fee at $175 per occurrence if less than 24 hours’ notice.
No show/missed appointment fee at $175 per occurrence.
Pro rata for services longer than 15 minutes.
Access to the Safe and Sound Protocol. If conducted in the office or virtually, there is a therapy session charge ($175) plus access to the music. In instances where the protocol is used at home, there are two options. Assessment plan with 3 music types = $250/month. Maintenance plan with 2 music types = $200/month. Factors affecting the difference include age of SSP client and access to emotional/physical safety. Clients will know ahead of sessions their specific charges.
EMDR Intensive packages are broken down as follows:
Initial intake (including free 30-minute consultation call) that lasts 2 hours (one hour is prior to session for planning, chart review and preparation for a cost of $460), 3 hours of EMDR processing ($690) and a 2-hour follow-up appointment ($460) for a total of= $1610.
Additional hours are charged at $230/hour and can be potentially added on to the initial Intensive date. If added on at later dates, then future sessions are in increments of 3- or 4-hour sessions ($690 or $920).
Weekend/non-business Intensives are packaged similarly but at a rate of $260/hour.
Snacks, drinks, therapeutic music, journals, and neck wraps are included as part of the service along with adjunct services to help keep clients regulated.
Additional services such as chiropractic releases can be added. I am happy to offer an alternative setting to allow for cranial massage and releases but will need to know ahead of time to make arrangements with the chiropractor. I have a professional relationship with Dr. Ryan Teeter (www.summitknox.com). I am happy to provide contact information and help assist in coordinating services to use during your Intensive.
Any Intensive that lasts 3+ hours may include a one-hour lunch on your own.
Once an Intensive session has been booked, I charge 50% deposit of the total fee. If something comes up and you are unable to attend your Intensive, please contact me as soon as possible to discuss rescheduling. Rescheduling will not affect your deposit or payment. If you need to cancel your Intensive entirely, you will lose your deposit. The remaining 50% will be paid on the first day of the Intensive. Clients who do not show or cancel with 48 hours’ notice or less, will be charged the full amount.
Estimated Annual Cost of Treatment
Please use the following equation to determine your annual estimated cost for treatment for this calendar year:
x session fee ($175) ✕ n number of sessions = $_____________Total
Example: 50 individual sessions/this calendar year ✕ $175 sessions fee = $8750 Total Cost.
Client Diagnosis
I may provide you with a mental health diagnosis ONLY AFTER completing a thorough intake assessment with you (the Client) and ONLY IF you meet criteria according to the DSM-5-TR. It is unethical and considered malpractice to provide a diagnosis prior to completing a full assessment. Therefore, we will not provide any diagnosis code on the Good Faith Estimate or until a full assessment is completed.
Good Faith Estimate Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate. Please visit www.cms.gov/nosurprises, call 800-985-3059 or contact your provider at 865-659-3412 for more information or to start your dispute claim.
“Thank you for allowing me to be a part of your journey and growth”