GOOD FAITH ESTIMATE
TABLE OF SERVICES AND FEES
| Service code (CPT Code) | Description | Fee for Service (Number of Sessions Will Be Determined as We Progress) |
| 90791 | Initial Diagnostic Evaluation | $220 |
| 90834 | Psychotherapy, 38-52 minutes | $140 |
| 90837 | Psychotherapy ≥ 53 minutes (This fee is my hourly rate & used for all prorated calculations as indicated) | $185 |
| 90839 | Psychotherapy for a Crisis (30-74 minutes) | $190 |
| +90840 | Psychotherapy for a Crisis (Add on code for each additional 30 mins) | $75 |
| 90846 | Family Psychotherapy without Patient Present, 50 minutes | $185 |
| 90847 | Family Psychotherapy with Patient Present, 50 minutes | $185 |
| 90853 | Group Psychotherapy | $100 |
| Case management | Letters, reports, consultations (These are not covered by insurance) | Prorated based on the amount of time spent at hourly rate |
| 98966-98968 | Telephone Assessment & Management | Prorated based on the amount of time spent at hourly rate |
| 98970-98972 | Online Digital Evaluation & Mgt (Responding to Email & Text Messages) | Prorated based on the amount of time spent at hourly rate |
| Cancelation Fee | Your Therapist Requires a 24-Hour Cancelation Fee | You are Responsible for the Fee of the Appointment Missed $145 |
| Production of Records | Will require 30 days to complete after written authorization | $50 |
| Legal Fees | Subpoenas, legal consultations, depositions. These will include travel times to and from venues if necessary. | $300/hr and can be prorated based on time spent |
| Total Estimate: | 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. |
Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical