Good Faith Estimate
This Good Faith Estimate outlines the reasonably anticipated costs of art therapy/psychotherapy services based on the information available at the time this estimate is provided. This estimate is not a contract and does not require you to obtain services from Lindsay Downs or The 3 Brushes, LLC.
This is not the official Good Faith Estimate form, but this form does include information and cost estimates that are typically included.
Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining the expected costs of healthcare services provided to you. Art therapy/psychotherapy is individualized, so it may not be possible to determine in advance the exact number of sessions or total cost of treatment for any specific person. This estimate is intended to provide a general overview of anticipated service costs. The total cost of care will depend on factors such as the frequency of sessions, individual treatment needs, and the types of services provided throughout treatment.
Additional services may occasionally be recommended as part of your care that are not included in this estimate and may need to be scheduled separately. This Good Faith Estimate only reflects the services specifically identified within this document.
You have the right to initiate a dispute resolution process if the actual charges substantially exceed the estimated costs listed in your Good Faith Estimate by $400 or more. For additional information about your rights under the No Surprises Act or the dispute resolution process, please visit:
CMS No Surprises Act Information or call 1-800-985-3059.
Initiating a dispute resolution process will not negatively affect the quality or availability of services provided to you.
Please note that the intake evaluation, also referred to as the initial assessment or diagnostic evaluation, is billed one time at a rate of $200. Ongoing psychotherapy sessions are billed according to the current session rates outlined in this estimate.
Parent and caregiver sessions may not be included in the Good Faith Estimate, as the frequency and clinical need for these sessions may vary throughout treatment. Family or caregiver sessions are often incorporated into the therapeutic process and may occasionally be scheduled separately. Your provider will discuss any recommended family or caregiver sessions with you in advance.
Session frequency is typically weekly or biweekly, though treatment recommendations may vary depending on your clinical needs and goals. The fee tables below provide estimated costs based on common treatment intervals over the course of a calendar year:
Weekly Sessions for A Full Calendar Year: 52 Sessions = $7,800
Biweekly Sessions for a Full Calendar Year: 26 Sessions = $3,900
Twice Weekly Sessions for a Full Calendar Year: 104 Sessions = $15,600
Monthly Sessions for a Full Calendar Year: 12 Sessions = $1,800
__________________________________________________________________________________________________________________
These calculations are based on approximate monthly timeframes
1 Month 4 Sessions = $600
3 Months 12 Sessions = $1,800
6 Months 24 Sessions = $3,600
9 Months 36 Sessions = $5,400
12 Months 52 Sessions = $7,800
___________________________________________________________________________________________________________________
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.
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.
Upon your request, or in the case of a crisis, additional services may be required or requested by you. The list of all services and fees is part of your informed consent form. Separate good-faith estimates will be issued upon request and added to your secure client portal.
If there is an update to the charges for services, I will provide you with 30 days’ notice of the change of fee and provide options regarding continuing, transferring, or discontinuing services. There may be additional items or services your provider recommends as part of psychotherapy that must be scheduled or requested separately not reflected in the good faith estimate; The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual item, services, diagnosis or charges may differ from the good faith estimate; and You have the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; this disclaimer must include instructions for where an uninsured (or self-pay) individual can find information about how to initiate the patient-provider dispute resolution process and state that the initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility; and this good faith estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified in the good faith estimate. You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give clients/patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.