GOOD FAITH ESTIMATE

Good Faith Estimate (GFE) for Therapy Services at Bisenius Counseling

Provider: John Bisenius, LMHC NPI: 1437558004

Federal law requires that clients who are uninsured or choosing not to use insurance receive a Good Faith Estimate of expected therapy costs. This is not a contract and does not obligate you to receive services.

If using insurance, expect to check the following information under your plan:

Copay/Coinsurance (if known)

Deductible Remaining

This estimate reflects self‑pay rates only. Your actual cost may differ based on your insurance company, benefits, deductibles, and claims processing.

If not using insurance / self‑pay: (Length of Treatment depends on presenting concerns and symptoms/severity.)

You will be charged the rates listed below.

Service

Diagnostic Assessment (Intake)

$ 175

Individual Therapy (60 min)

$ 125

Individual Therapy (45 min)

$ 100

Family/Couples Therapy

$ 125

Other: 30-minutes session

$ 75

Some additional costs may include late cancellation fees, letters/reports, court‑related services, extended sessions, or crisis appointments. If additional services are recommended, a revised estimate will be provided.

Your Rights

If your bill is $400 or more above this estimate, you may dispute the charge through the federal patient‑provider dispute resolution process. You may also request an updated estimate at any time.