Good Faith Estimate for Mental Health Counseling Services
Issued by Black Bold and Learning, LLC
Provider: Jasmine Jaquess, Provisionally Licensed Clinical Mental Health Counselor
Client Name: Example
Date Issued: Date of Intake
Overview of Services
This Good Faith Estimate provides an overview of the costs associated with therapy services for one year at Black Bold and Learning, LLC. As a private pay practice, we provide an upfront estimate based on the current rate of $125 per session for weekly sessions. Therapy is a flexible process, and session frequency can be adjusted based on your needs.
Estimated Annual Cost
Weekly Therapy (52 weeks, minus holidays/closed dates):
Estimated Cost: 48 sessions x $125 = $6,000 per year
Potential Cost Range for Bi-Weekly or Monthly Therapy:
Bi-Weekly: 26 sessions x $125 = $3,250 per year
Monthly: 12 sessions x $125 = $1,500 per year
This range reflects possible changes in frequency as you progress through therapy and is not an obligation. Please note that this estimate excludes holidays or planned office closures.
Sliding Scale Option
Black Bold and Learning, LLC offers a sliding scale to provide financial flexibility. Rates on the sliding scale start at $70 per session and go up to the standard rate of $125 per session. Eligibility for the sliding scale can be discussed directly with your provider if financial accommodations are needed.
Insurance Information and Private Pay Policy
Black Bold and Learning, LLC operates as a private pay practice and does not accept insurance directly. However, if you wish to use insurance, you may work with Jasmine Jaquess through Higher Sites Counseling, a separate practice that bills insurance. You may request Jasmine as your counselor through Higher Sites if you decide to utilize insurance.
For private pay clients who wish to seek reimbursement, we can provide a superbill upon request. However, please note that reimbursement is not guaranteed, as it is up to your insurance provider to determine if any or all costs will be reimbursed.
Estimated Out-of-Pocket Costs with Insurance Reimbursement
If you submit a superbill to your insurer, your out-of-pocket costs may be reduced depending on your insurer’s reimbursement rate. For example:
50% Insurance Reimbursement: Estimated annual out-of-pocket cost = $3,000 for weekly sessions.
Please verify your insurer’s policies, as reimbursement rates and eligibility vary.
Additional Considerations
Emergency and Crisis Services
Black Bold and Learning, LLC does not provide emergency or crisis intervention services. If you experience a mental health emergency, please contact emergency services, visit the nearest emergency room, or call a crisis hotline for immediate support.
Annual Review of Therapy Goals
Therapy is a collaborative process, and we will review your progress and goals regularly to ensure sessions align with your evolving needs. Adjustments to the frequency or duration of therapy can be made at any time based on what feels manageable and helpful to you.
Client Rights and Protections under the No Surprises Act
As a client, you have the right to request a revised Good Faith Estimate at any time or discuss cost and frequency changes with me. This estimate is based on current fees and frequency; however, should rates change, you will be informed with ample notice. Therapy is a personal investment, and any updates to pricing will be communicated in advance.
Acknowledgment
By signing below, you acknowledge that you have received and reviewed this Good Faith Estimate and understand the financial responsibility involved in engaging in therapy services at Black Bold and Learning, LLC.
Client Signature: _______________________
Date: _______________________