Stillwater Cove Therapy, PLLC
Provider: Meagan Restaino, LCPC, NCC, CADC, PCGC

Your Right to a Good Faith Estimate

Under federal law (the No Surprises Act), you have the right to receive a Good Faith Estimate of the expected cost of mental health services if you are not using insurance or if you choose to self-pay.

A Good Faith Estimate helps you understand the expected cost of services before beginning treatment. This Good Faith Estimate is based on the information known at the time it is provided. It is not a contract and does not guarantee the total cost of services. Actual charges may vary based on clinical needs, session length, frequency of sessions, or additional services provided.

What the Estimate Includes

Your Good Faith Estimate will outline:

• Anticipated services (based on current clinical information)

• Expected session length and frequency

• Estimated total cost over a given period of time

• Any applicable fees for additional services, if relevant

Self-Pay Rates

The following are the standard self-pay rates for services that may be provided:

• 90791 – Diagnostic Evaluation: $225

• 90832 – Individual Psychotherapy (30 minutes): $130

• 90834 – Individual Psychotherapy (45 minutes): $165

• 90837 – Individual Psychotherapy (60 minutes): $210

• 90846 – Family Psychotherapy (without client present): $165

• 90847 – Family Psychotherapy (with client present): $210

• 90785 – Interactive Complexity (add-on, when clinically indicated): $40

• 90853 – Group Psychotherapy: $75

Example of Estimated Cost (Ongoing Treatment)

If you attend one 45-minute individual psychotherapy session per week (90834), the estimated cost would be:

• $165 per session

• Approximately $660 per month (4 sessions)

This estimate may change if:

• Session length changes

• Frequency of sessions changes

• Different or additional services are provided

• Interactive complexity is clinically indicated

Sliding Scale

Sliding scale or reduced-fee openings may become available on a limited basis and based on availability. If a reduced-fee rate is approved, it will be documented separately and will supersede the standard rates listed above.

Dispute Resolution Rights

If you are a self-pay or uninsured client and receive a bill for services that is $400 or more above your Good Faith Estimate, you have the right to initiate the federal patient-provider dispute resolution process.

This process must be initiated within 120 days of receiving the bill.

Information about the dispute resolution process is available through the Centers for Medicare & Medicaid Services (CMS):
www.cms.gov/nosurprises

Important Notice

This Good Faith Estimate applies only to self-pay or uninsured services. It does not apply to clients using insurance benefits, including those with deductibles, copayments, or coinsurance.

How to Request a Good Faith Estimate

If you would like to request a Good Faith Estimate before scheduling or at any time, please contact:

Stillwater Cove Therapy, PLLC
Email: hello@stillwatercovetherapy.com