....
National Alliance for Mental Health
866-615-6464
800-969-6642 
www.nmha.org
www.nimh.nih.gov
Depression & Bipolar Support
National Alliance for the Mentally Ill
Alliance 800-826-3632
800-950-62 www.nami.org
www.dbsalliance.org
American Association for Marriage
& Family Therapists
703-838-9808
www.AAMFT.org
American Psychological Association
800-374-2721
www.apa.org
Georgia Psychological Association
404-634-6272
www.gapsychology.org
| Good Faith Estimate and table of services of and fees Dear Client, In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.” This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance. Additionally, we are required to provide you with a Good Faith Estimate of the cost of services (attached). It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, attached you will find a fee schedule for the services typically offered by your therapist, and we will collaborate with you on a regular basis to determine how many sessions you may need Thank you very much, This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns .
| | .Service code (CPT Code) | Description | Fee for Service (Number of Sessions Will Be Determined as We Progress) | | | 90791 | Initial Diagnostic Evaluation | $160.00 | | | 90832 | Psychotherapy, 16-37 minutes | Pro-rated fee | | | 90834 | Psychotherapy, 38-52 minutes | Pro-rated fee | | Estimate by number of sessions | 90837 | Psychotherapy ≥ 53 minutes (This fee is my hourly rate & used for all prorated calculations as indicated) | $150.00 | | | 90839 | Psychotherapy for a Crisis (30-74 minutes) | Pro-rated fee | | | +90840 | Psychotherapy for a Crisis (add on code for each additional 30 mins) | Pro-rated Fee | | | 90846 | Family Psychotherapy without Patient Present, 50 minutes | $150.00 | | | 90847 | Family Psychotherapy with Patient Present, 50 minutes | $150.00 | | | 98966- 98968 | Telephone Assessment & Management | Prorated based on the amount of time spent at hourly rate | | | 98970- 90872 | Online Digital Evaluation & Mgt (Responding to Email & Text Messages) | Prorated based on the amount of time spent at hourly rate | | | Cancelation Fees | Therapist Requires a 24-Hour Cancelation Fee | You are Responsible for the Fee of the Appointment Missed | | | Production of Records/Legal Fees | | Prorated rate | | | | . | | | | | | | | *Please Note: | | Tele-health services are charged at identical rate | |
| |
