GOOD FAITH ESTIMATE

Good Faith Estimate

You are entitled to receive this Good Faith Estimate of what the charges could be for couples therapy, individual therapy, or couples intensives provided to you.

While it is not possible to know in advance how many sessions may be necessary or appropriate for a given client or couple, this estimate provides an overview of the cost of services that may be provided. Your total cost will depend on the number of sessions you attend, your individual circumstances, and the type and amount of services 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 not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction of the number of sessions you may need. The number of sessions appropriate for your situation, 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 regarding your treatment, and you may discontinue treatment at any time.

Fees (1)

Couples Intensive

The cost of an intensive is $5,000

Couples Therapy

The cost of a 80-minute session is $300

Individual Therapy

The cost of a 50-minute session is $200

Good Faith Estimate — Costs and Your Rights

This Good Faith Estimate shows the costs of items and services reasonably expected for your health care needs. The estimate is based on information known at the time it was created and is valid for 12 months from the date of this Good Faith Estimate.

Unexpected Costs This Good Faith Estimate does not include unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If your bill is $400 or more above this Good Faith Estimate for any provider or facility, federal law allows you to dispute the bill.

How to Dispute Your Bill You may contact the 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 estimate, negotiate the bill, or inquire about financial assistance. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). The dispute process must be initiated within 120 calendar days (approximately 4 months) of the date on the original bill.

Your Protections During a Dispute If you dispute your bill, the provider or facility cannot move the bill into collections, threaten to do so, or take any retributive action against you. If the bill is already in collections, collection efforts must cease. The accrual of any late fees must also be suspended until the dispute resolution process has concluded.

Dispute Resolution Fees There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity agrees with you, you will pay the amount on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity agrees with the provider or facility, you will pay the higher amount.

Questions or More Information You are encouraged to speak with your provider at any time about your treatment plan or this Good Faith Estimate. For more information about your rights or the dispute process:

Please keep a copy of this Good Faith Estimate in a safe place. You may need it if you are billed a higher amount.

PRIVACY ACT STATEMENT CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). This information is needed to process your request to initiate a payment dispute, verify eligibility, and determine whether any conflict of interest exists with the selected independent dispute resolution entity. It may also be used to support the decision on your dispute, oversee the PPDR program, and evaluate the selected IDR entity’s compliance with program rules. Providing the requested information is voluntary, but failing to do so may delay or prevent the processing of your dispute, or cause your dispute to be decided in favor of the provider or facility.