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.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. 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.

You have the 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).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $150 and initial psychiatric diagnostic assessment (intake) is $180. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $180 for intake appointment and $150 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $180 + $450 ($630) for four visits provided over the course of one month; $180 + $1,050 ($1,230) for eight visits over two months; or $180 + $1,650 ($1,830) for 12 visits over three months. If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.

Common Services at Growth and Compassion Therapy

• 90791: Initial therapy intake 

• 90837: Ongoing therapy appointments 

• 90834: Ongoing therapy appointments

• 90847: Family/Couples appointments 

• 90846: Collateral appointments

Common Diagnosis Codes at Growth and Compassion Therapy:

Below are common diagnosis codes at Growth and Compassion Therapy; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns. 

Adjustment Disorder (F43.23), Mental Disorder, Not Otherwise Specified (F99), Depression (F32.9) Anxiety (F41.1), Bipolar (F31.9), PTSD/Post Traumatic Stress Disorder (F43.10).

Growth and Compassion Therapy recognizes every client's therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including:

• Your schedule and life circumstances 

• Therapist availability 

• Ongoing life challenges 

• The nature of your specific challenges and how you address them - Personal finances

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Where services will be delivered:

Growth and Compassion Therapy is an exclusively telehealth practice; as such, all benefits will be quoted as virtual.

Growth and Compassion Therapy business address: 4695 MACARTHUR COURT, STE 1100 #5357, NEWPORT BEACH, CA 92660

Clinicians Available at Growth and Compassion Therapy:

• Wan-Ning Linda Lo, LMFT 128294

• Marlene Cortes, LMFT 144195

Client Diagnosis

At Growth and Compassion Therapy, we must diagnose all clients for both ethical, legal, and insurance reasons--as well as required by the "No Surprises Act".

Your Good Faith Estimate diagnosis is:

• Primary Diagnosis: Z73.3 - Stress not elsewhere specified 

• Secondary Diagnosis: F99 - Mental Health Disorder, Not Otherwise Specified

This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update this GFE. It is within your rights to decline a diagnosis per state and federal guidelines.

Primary Service or Item Requested/Scheduled

• Individual Psychotherapy

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.

Date of this Estimate/Today's Date: 11/21/2024