As part of the No Surprises Act, a Good Faith Estimate (GFE) serves to protect clients from large, surprise bills. These bills typically result from emergency medical care, ambulance services, and certain services received from out-of-network providers at in-network facilities.

This does not change how I run my practice, as I have always been transparent and clear about my fees for services I offer to clients before scheduling their first appointment. New clients are always provided with comprehensive forms that outline the expenses involved before their intake session. Additionally, the current fees for therapy sessions are readily accessible on my website under "Cost of Services" (with the exception of fees for couples therapy as I am not currently taking on new couples, but do note I still provide the current fees for couples below). Participation in my services is entirely voluntary, and clients have the freedom to choose another qualified provider if they have concerns or preferences regarding costs or any of my policies.

Below, you will find two current Good Faith Estimates (GFE) for your reference for INDIVIDUAL THERAPY services and COUPLES THERAPY services scheduled during the 2023 calendar year. Please be aware that these costs are subject to change. If there are any modifications to the below session costs, you will be informed in advance before services are rendered. It's important to note that each estimate DOES NOT include additional fees that may be applicable to you over the course of therapy services. These additional fees may consist of incident charges, such as fees for cancellations, missed appointments, and returned payments due to insufficient funds, as well as potential court/legal fees. These fees are situational and dependent on individual client circumstances and actions. While these fees are associated with instances that may arise during therapy, they are not inherent components of the therapy process itself. While not required, for sake of transparency and for your convenience, I have included a list of these potential fees after the estimates below.

How long will I be in therapy for?

The number of sessions you may require cannot be precisely determined in advance, as the duration of our work together is dependent on various factors unique to your circumstances, needs, and experiences. Therapy is a personalized journey and like any other relationship, time is essential in building a therapeutic bond. Developing a more clear and comprehensive understanding of your needs and goals will take some time and exploration.

The duration and frequency of your therapy sessions may be influenced by many factors, including but not limited to:

• Your scheduling availability

• Current life situations you may be navigating

• Changes that may affect your ability to attend sessions or engage in therapy

• The need for specialized assessments or interventions

• Your own motivation and commitment to the therapeutic process

• The therapist's availability and any scheduling constraints

• Your personal finances and financial resources

Regardless of the number of sessions we have, my aim is to support your individual needs to the best of my ability. Together, we will collaborate to work towards meeting your goals and make every effort to ensure that our time together is valuable and effective for you.

A Good Faith Estimate (GFE) in healthcare focuses on providing an estimate of the costs associated with specific services. Incidental fees, such as the fees listed below, are not required to be included in a GFE, as they are specific to the terms and policies of a healthcare provider or facility.

For your convenience, I have included a list of circumstantial and situational fees that could be incurred during the course of therapy services. Please note that these fees are separate and in addition to the cost of therapy sessions:

• More Than 24 hours Notice for Cancellation/Reschedule = No Charge

• 24 Hours or Less Notice for Cancellation/Reschedule = Full appointment fee charged

• Late Arrivals (1 - 20 minutes late) = No fee is charged but your session will end at the scheduled time

• Late Arrivals (more than 20 minutes late) = Your session is subject to cancelation and will be charged the full appointment fee

• No Show/Missed Appointment* = Full appointment fee charge

• Cancelation, Reschedule, and/or No Show of Same-Day Appointment = Charged the full appointment rate, plus an additional $35.00

• Cancelation of a Rescheduled Appointment** = Charged the full appointment fee twice

• Bounced/Returned Check = $30 fee to cover the cost of the bank penalty fee

• Payment Declined Due to Insufficient Funds (NSF) = $30 fee each unsuccessful transaction attempt

• The minimum charge for a court appearance: $3000 (a detailed breakdown regarding current court/litigation fees can be found in the ‘Payment and Fees Policies’ that are provided as part of your intake paperwork)

• Unpaid Balance Lasting 30 Days or More = Your debt may be sent to collections and any costs I incur resulting from the collection of your payment are your responsibility

*"No Show/Missed Appointment" refers to a situation where a client fails to attend a scheduled appointment without providing notice or canceling the appointment prior to the scheduled appointment start time. It means that the client does not show up for the scheduled session, resulting in a missed opportunity for therapy or service provision. If a client tries to provide notice of their absence after the scheduled appointment start time, it is still considered a missed appointment or no-show.

**"Cancellation of a Rescheduled Appointment" refers to the act of canceling an appointment that was previously rescheduled for a different date or time. It means that after rescheduling an appointment, if the client decides to cancel it again, it will be considered a cancellation of the rescheduled appointment.

Please note, frequent (defined as 3 or more in 6 months or 2 consecutive) instances of late cancellations and/or reschedules and/or no-shows may result in services being discontinued. If you are unable to attend scheduled appointments on a regular basis, you will likely benefit from being referred out to a provider or practice that may better meet your scheduling needs.

Additionally, if you are DRIVING during your session or OPERATING HEAVY EQUIPMENT/MACHINERY (which is not permitted under any circumstance) you will be asked to pull over. If you are unable to pull over to have your session, your appointment will be considered canceled and you will be charged the full fee.

GOOD FAITH ESTIMATE NOTICE:

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

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.

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

The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

If you are billed for more than this Good Faith Estimate, you may 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.

If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.

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

To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

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). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.