Good Faith Estimate

 You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy 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 psychotherapy 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 Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy 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.

The fee for a 45-minute psychotherapy visit (in person or via telehealth) is $ 225. Most clients will attend one to five psychotherapy visits per week, depending upon your needs. The frequency is discussed and verbally agreed upon between clinician and client based on treatment recommendations and client's ability to attend at the recommended frequency. In addition to weekly appointments, I charge for telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Legal work is charged at $185 per hour. Based on a fee of $185 per visit, the following are expected charges of psychotherapy services:

1 week in once weekly therapy service annually: $225.00

13 weeks in once weekly therapy/ approx. 3 months of service: $2925.00

26 weeks in once weekly therapy/ approx. 6 months of service: $5850.00

39 weeks in once weekly therapy/ approx. 9 months of service: $8775.00

52 weeks in once weekly therapy/ approx. 12 months of service: $11,700.00

1 week of 2 sessions per week therapy service: $450.00

13 week of 2 sessions per week therapy service/ approx. 3 months of service: $5,850.00

26 week of 2 sessions per week therapy service/ approx. 6 months of service: $11,700.00

39 week of 2 sessions per week therapy service/ approx. 9 months of service: $17,550.00

52 week of 2 sessions per week therapy service/ approx. 12 months of service: $23,400.00

1 week of 3 sessions per week therapy service: $675.00

13 week of 3 sessions per week therapy service/ approx. 3 months of service: $8775.00

26 week of 3 sessions per week therapy service/ approx. 6 months of service: $17,550.00

39 week of 3 sessions per week therapy service/ approx. 9 months of service: $26,325.00

52 week of 3 sessions per week therapy service/ approx. 12 months of service: $35,100.00

1 week of 4 sessions per week therapy service: 900.00

13 week of 4 sessions per week therapy service/ approx. 3 months of service: $11,700.00

26 week of 4 sessions per week therapy service/ approx. 6 months of service: $23,400.00

39 week of 4 sessions per week therapy service/ approx. 9 months of service: $35,100.00

52 week of 4 sessions per week therapy service/ approx. 12 months of service: $46,800.00

You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

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.

Date of this Estimate 11/10/23