Good Faith Estimate

Collected Connections Counseling & Consulting has set the following fees for services:

$150 per 50 minute session

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.

Costs for services provided are outlined above. The following estimate is based on the fee for a 50

minute psychotherapy visit (in person or via telehealth) at $150 and does not include costs of other

services that may be indicated as part of treatment. The frequency and length or type (family vs

individual) of psychotherapy visits that are appropriate in your case may vary depending upon your

needs. Based on a fee of $150 per visit, the following are expected charges of psychotherapy services:

Number of Weeks

Total estimated charges for 1 session per week (weekly)

4 Weeks of Service (Approx. 1 month) $600

13 Weeks of Service (Approx. 3 Months) $1950

26 Weeks of Service (Approx. 6 months) $3900

39 Weeks of Service (Approx. 9 months) $5850

52 Weeks of Service (Approx. 12 Months) $7800

Total estimated charges for 1 session every other week (bi-weekly)

4 Weeks of Service (Approx. 1 month) $150

13 Weeks of Service (Approx. 3 Months) $1050

26 Weeks of Service (Approx. 6 months) $1950

39 Weeks of Service (Approx. 9 months) $3000

52 Weeks of Service (Approx. 12 Months) $3900

Total estimated charges for 1 session per month (monthly)

4 Weeks of Service (Approx. 1 month) $150

13 Weeks of Service (Approx. 3 Months) $450

26 Weeks of Service (Approx. 6 months) $900

39 Weeks of Service (Approx. 9 months) $1350

52 Weeks of Service (Approx. 12 Months) $1800

Disclaimers

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 and is subject to change. This estimate does not include one-off sessions or if you

choose to increase frequency of sessions or family, parent, couple counseling is indicated and

scheduled. Also not included in the estimate are any case management fees that may incur, which will

be discussed between you and your therapist as these services are indicated.

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,

federal law allows you to dispute (appeal) the bill.

The Good Faith Estimate is not a contract and does not require you to obtain the services from the

provider identified on the Good Faith Estimate.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

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.

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.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800)

368-1019.

For questions or more information about your right to a Good Faith Estimate or the dispute process,

visit www.cms.gov/nosurprises or call (800) 368-1019.

Payment Collection

It is the policy of Collected Connections Counseling & Consulting to collect all fees at the time of

service unless other arrangements for payment have been made between you and your therapist and

both agree to this in writing. Group therapy clients have specific payment agreements (see group

specific informed consent form for fees). In addition, your therapist requests you complete a “Credit

Card Authorization” form to keep in your file.

It is the policy of Collected Connections Counseling & Consulting to keep a credit card on file in our

secure billing system and that charges will be run after service is provided unless other arrangements

for payment have been made between you and your therapist. Upon your request, you may receive a

receipt for charges.

Collected Connections Counseling & Consulting is not currently an in-network provider for any

insurance companies.

Collected Connections Counseling & Consulting increases rates on occasion and will notify you of these

increases at minimum a month in advance.

For billing and fee related questions you may contact your therapist directly or Collected Connections

Counseling & Consulting practice owner, Kristin Crumbley at KristinCrumbley.LMHC.LMFT@gmail.com.