The “Good Faith Estimate” of what you could pay if you choose to enter treatment is as follows:

I understand that Alexandria Scalone, my clinician, may provide the following services:

• Individual Psychotherapy

• Family Psychotherapy With Patient Present

• Family Psychotherapy without Patient Present (Most known as parent meetings)

• Psychiatric Diagnostic Evaluation

• CPT Codes 90834, 90837, 90847, 90846, 90791

My hourly rate for the service above is $200 per session.

• This represents a “good faith estimate” only of the total annual amount you may be asked to pay and is NOT a contract. It is only an estimate.

• The actual number of visits per year may vary significantly depending on the frequency of visits.

• If there is a dispute about this estimate, you may contact the Department of Health and Human Services within 120 days of the service outlined in this estimate.

Should you have additional questions about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the “No Surprises” Help Desk at 800-985-3059.