Therapy is an extremely personal experience tailored to the needs of the client and the presenting concerns. Due to the nature of this unpredictability and Cor Sacrum Counseling and Consulting, PLLC commitment to meeting and catering to the needs of every client individually, determining duration of treatment is ethically impossible. The industry standard of most Health Insurance companies is 12-15 sessions. You and your therapist will continue to review progress and make personalized decisions regarding both the frequency and duration of treatment periodically. Per your informed consent, you can decide at any time to terminate services. Due to this, all GFE’s will be based on weekly appointments/your current frequency over the course of a 12 month/52-week calendar year)

Diagnoses Used

*Please note Diagnostic codes provided here are generic and used to satisfy the requirements of the No Surprises Act. Per our verbal discussion and your signature verifying the review of the Informed Consent and Practice Policies, you understand that Diagnoses will only be provided for the purposes of submitting reimbursement claims to your healthcare insurance provider at your request. Any other diagnoses will be discussed between client and therapist for the purpose of treatment planning and referrals to appropriate providers*

F43.21 Adjustment Disorder with Depressed Mood
V61.29/Z62.898 Child Affected by Parental Distress
F43.22 Adjustment Disorder with Anxiety
V61.10/Z63 Relationships Distress with Spouse or Intimate Partner
F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood
V61.03/Z63.5 Disruption of Family by Divorce or Separation
F99.00 Mental Disorder, not otherwise specified
V15.49/Z91.49 Other Personal History of Psychological Trauma
V61.23/Z62.820 Parent-Child Relational Problem
V62.89/Z60.0 Phase of Life Problem
V62.9/Z60.9 Unspecified Problem Related to Social Environment
V62.9/Z65.8 Other Problem Related to Psychosocial Circumstances
MDD F32. Major depression disorder
GAD- F 41.1 Generalized Anxiety
F40.10 Social Phobia
F 41.0 Panic disorder
F 42 Obsessive compulsive disorder
F90.2/F90.0/F90.1 ADHD, combined type; inattentive type; hyperactive type
F43.10 Post Traumatic Stress Disorder
F25.0 or F 25.1 Schizoaffective disorder , depressed or bipolar type
F31.0/ F31.1 / F31.3 Bipolar disorder Type I- hypomanic, manic or depressed current state
F31.81 Bipolar Type II
F 50.8. Binge Eating disorder
F50.2 Bulimia nervosa
F34.8 DMDD Disruptive Mood dysregulation disorder
N94.3 Premenstrual dysphoric disorder
F 63.81 Intermittent explosive disorder
F91.3 Oppositional Defiant disorder
F 91. Conduct Disorder

Health Insurance Waiver

As both verbally discussed and as indicated by your signature on the Informed Consent and Practice Policies, you understand that Cor Sacrum Counseling and Consulting, PLLC does not accept insurance as a method of payment. By using these services, you understand you are waiving the usage of your insurance. You are, however, more than welcome to use your HSA/FSA accounts for payment. You are responsible for understanding your own insurance benefits to include the co-pays and deductibles coverages available to you by choosing to work with a mental health provider within your insurance company’s network. Those amounts may or may not be less than the fees you are agreeing to pay Cor Sacrum Counseling and Consulting, PLLC. Your signature on this GFE indicates your waiver of insurance benefits and paying the out-of-pocket fees as listed above.
At any time, you may request an Out of Network Billing statement(s) or Superbill from Cor Sacrum Counseling and Consulting, PLLC. This statement will include Dates of Service, Billing Codes, and Diagnostic Codes. You may choose to submit these statement(s) to your insurance company in an effort to request full or partial reimbursement. Your signature on this GFE indicates that the reimbursement decision is that solely of your insurance provider and Cor Sacrum Counseling and Consulting, PLLC in no way guarantees or has authority in this reimbursement decision. We cannot supply Out of Network Billing statement(s) or Superbills for Medicare/Medicaid insurance.

*In an effort to reduce paper waste, this form will be kept in your client confidential file. If you would like a copy for your records, please request*

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. • Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 368-1019.

Frequency and Duration of Treatment: Depending on your treatment needs, services will be provided for a frequency of one of the following and may fluctuate throughout the duration of treatment:

A) Weekly
B) Bi-weekly
C) Monthly (reserved for clients who have met treatment goals as defined by both client and therapist)
D) As-needed maintenance (reserved for clients who have met treatment goals as defined by both client and therapist)

Primary Services Provided and Associated Fees for Maribel Laguna, MA, LPC-S, CSAT Candidate
*Please note CPT codes will only be used for the purpose of your submission of reimbursement claims to your healthcare insurance provider*
A) Psychiatric Diagnostic Evaluation (50 mins) CPT 90791 = $225
B) Telehealth Psychiatric Diagnostic Evaluation (50 mins) CPT 90971GT = $225
C) Individual Psychotherapy (50 mins) CPT 90837 =$200
D) Telehealth Individual Psychotherapy (50 mins) CPT 90837GT =$200
E) Family or Couples Psychotherapy (50 Mins) CPT 90847= $245 for the intake session and $225 for each
follow up session.
F) Telehealth Family or Couples Psychotherapy (50 Mins) CPT 90847GT= $245 for the intake session and $225
for each follow up session.
G) Psychotherapy for Crisis (50 mins) CPT 90839=$200
H) Telehealth Psychotherapy for Crisis (50 mins) CPT 90839GT=$200

Other Services and Fees *These Fees are not eligible for discounts or sliding scale and due to
the unpredictable nature of each client’s needs will not be included in the GFE. This information
serves as notice of additional fees you may incur based on your personal needs*
A) Unscheduled/Ad-Hoc/Crisis/Parent Consultation Phone Calls > 15 mins= prorated @ $35/15 mins
B) Requested Documentation to Include Treatment Summary, Other Provider Consultation, Superbill, Other
Written Letters =prorated @ $100/1hr
C) No Call No Show to Scheduled Appointment (as defined in the informed consent)- $225 for the intake
session and $200 for each follow up session.

D) Cancelled Appointment less than 48 Hours before appointment (without same- week reschedule, as
defined in your informed consent) = $225 for the intake session and $200 for each follow up session.

Personal Cost Estimation
1) For Individual therapy, your current fee per session is: $225 for the intake session and
$200 for each follow up session. You are currently scheduling sessions weekly. Based on
a 52-week calendar year, your total estimated cost of treatment, not including holidays,
breaks, and other unpredictable fees/services disclosed above, will be $10,425.
If you are seeing your provider biweekly, your total estimated cost of treatment per 52
week year would be $5,325.
If you are seeing your provider monthly, your total estimated cost of treatment per 52
week year would be $2,425.
2) For Marriage/Family therapy, your current fee per session is: $245 for the intake session
and $225 for each follow up session. You are currently scheduling sessions weekly. Based
on a 52-week calendar year, your total estimated cost of treatment, not including
holidays, breaks, and other unpredictable fees/services disclosed above, will be $11,700.
If you are seeing your provider biweekly, your total estimated cost of treatment per 52
week year would be $5,850.
If you are seeing your provider monthly, your total estimated cost of treatment per 52
week year would be $2,425.

Primary Services Provided and Associated Fees for Sonia Mijares, MA, LPC-S
*Please note CPT codes will only be used for the purpose of your submission of reimbursement claims to your healthcare insurance provider*
A) Psychiatric Diagnostic Evaluation (50 mins) CPT 90791 = $225
B) Telehealth Psychiatric Diagnostic Evaluation (50 mins) CPT 90971GT = $225
C) Individual Psychotherapy (50 mins) CPT 90837 =$200
D) Telehealth Individual Psychotherapy (50 mins) CPT 90837GT =$200
G) Psychotherapy for Crisis (50 mins) CPT 90839=$200
H) Telehealth Psychotherapy for Crisis (50 mins) CPT 90839GT=$200

Other Services and Fees

*These Fees are not eligible for discounts or sliding scale and due to
the unpredictable nature of each client’s needs will not be included in the GFE. This information
serves as notice of additional fees you may incur based on your personal needs*
A) Unscheduled/Ad-Hoc/Crisis/Parent Consultation Phone Calls > 15 mins= prorated @ $35/15 mins
B) Requested Documentation to Include Treatment Summary, Other Provider Consultation, Superbill, Other
Written Letters =prorated @ $100/1hr
C) No Call No Show to Scheduled Appointment (as defined in the informed consent)- $225 for the intake
session and $200 for each follow up session.

D) Cancelled Appointment less than 48 Hours before appointment (without same- week reschedule, as
defined in your informed consent) = $225 for the intake session and $200 for each follow up session.

Personal Cost Estimation
For Individual therapy, your current fee per session is: $225 for the intake session and
$200 for each follow up session. You are currently scheduling sessions weekly. Based on
a 52-week calendar year, your total estimated cost of treatment, not including holidays,
breaks, and other unpredictable fees/services disclosed above, will be $10,425.
If you are seeing your provider biweekly, your total estimated cost of treatment per 52
week year would be $5,325.
If you are seeing your provider monthly, your total estimated cost of treatment per 52
week year would be $2,425.

Estimation of fees for EMDR Intensives will also be provided upon request and scheduling.

Primary Services Provided and Associated Fees for Gina Neff, LPC-Associate

Supervised by Melissa Harrison, LPC-S

*Please note CPT codes will only be used for the purpose of your submission of reimbursement claims to your healthcare insurance provider*

A) Psychiatric Diagnostic Evaluation (50 mins) CPT 90791 = $160

B) Telehealth Psychiatric Diagnostic Evaluation (50 mins) CPT 90971GT = $160

C) Individual Psychotherapy (50 mins) CPT 90837 =$150

D) Telehealth Individual Psychotherapy (50 mins) CPT 90837GT =$150

E) Family or Couples Psychotherapy (50 Mins) CPT 90847= $180 for the intake session and $170 for each follow up session.

F) Telehealth Family or Couples Psychotherapy (50 Mins) CPT 90847GT= $180 for the intake session and $170 for each follow up session.

G) Psychotherapy for Crisis (50 mins) CPT 90839=$150

H) Telehealth Psychotherapy for Crisis (50 mins) CPT 90839GT=$150

Other Services and Fees

*These Fees are not eligible for discounts or sliding scale and due to the unpredictable nature of each client’s needs will not be included in the GFE. This information serves as notice of additional fees you may incur based on your personal needs* A) Unscheduled/Ad-Hoc/Crisis/Parent Consultation Phone Calls > 15 mins= prorated @ $35/15 mins B) Requested Documentation to Include Treatment Summary, Other Provider Consultation, Superbill, Other Written Letters =prorated @ $100/1hr C) No Call No Show to Scheduled Appointment (as defined in the informed consent)- $160 for the intake session and $150 for each follow up session. D) Cancelled Appointment less than 48 Hours before appointment (without same- week reschedule, as defined in your informed consent) = $160 for the intake session and $150 for each follow up session.

Personal Cost Estimation

1) For Individual therapy, your current fee per session is: $160 for the intake session and $150 for each follow up session. You are currently scheduling sessions weekly. Based on a 52-week calendar year, your total estimated cost of treatment, not including holidays, breaks, and other unpredictable fees/services disclosed above, will be $7,810. If you are seeing your provider biweekly, your total estimated cost of treatment per 52 week year would be $3,910. If you are seeing your provider monthly, your total estimated cost of treatment per 52 week year would be $1,810.

2) For Marriage/Family therapy, your current fee per session is: $180 for the intake session and $170 for each follow up session. You are currently scheduling sessions weekly. Based on a 52-week calendar year, your total estimated cost of treatment, not including holidays, breaks, and other unpredictable fees/services disclosed above, will be $8,850. If you are seeing your provider biweekly, your total estimated cost of treatment per 52 week year would be $4,420. If you are seeing your provider monthly, your total estimated cost of treatment per 52 week year would be $2,050.

Primary Services Provided and Associated Fees for Rickie Jacob, LPC-Associate
Supervised by Sonia Mijares, MA, LPC-S

*Please note CPT codes will only be used for the purpose of your submission of reimbursement claims to your healthcare insurance provider*
A) Psychiatric Diagnostic Evaluation (50 mins) CPT 90791 = $140
B) Telehealth Psychiatric Diagnostic Evaluation (50 mins) CPT 90971GT = $140
C) Individual Psychotherapy (50 mins) CPT 90837 =$130
D) Telehealth Individual Psychotherapy (50 mins) CPT 90837GT =$130
G) Psychotherapy for Crisis (50 mins) CPT 90839=$130
H) Telehealth Psychotherapy for Crisis (50 mins) CPT 90839GT=$130
I) Prolonged service in an outpatient setting (EMDR Intensive - 180 ins) CPT 99354 = $300

Other Services and Fees

*These Fees are not eligible for discounts or sliding scale and due to the unpredictable nature of each client’s needs will not be included in the GFE. This information serves as notice of additional fees you may incur based on your personal needs* A) Unscheduled/Ad-Hoc/Crisis/Parent Consultation Phone Calls > 15 mins= prorated @ $35/15 mins B) Requested Documentation to Include Treatment Summary, Other Provider Consultation, Superbill, Other Written Letters =prorated @ $100/1hr C) No Call No Show to Scheduled Appointment (as defined in the informed consent)- $140 for the intake session and $130 for each follow up session. D) Cancelled Appointment less than 48 Hours before appointment (without same- week reschedule, as defined in your informed consent) = $140 for the intake session and $130 for each follow up session.

Personal Cost Estimation:
For Individual therapy, your current fee per session is: $140 for the intake session and
$130 for each follow up session. You are currently scheduling sessions weekly. Based on
a 52-week calendar year, your total estimated cost of treatment, not including holidays,
breaks, and other unpredictable fees/services disclosed above, will be $6,770
If you are seeing your provider biweekly, your total estimated cost of treatment per 52
week year would be 3,385

If you are seeing your provider monthly, your total estimated cost of treatment per 52
week year would be $1,570

Primary Services Provided and Associated Fees for Amy Walsh, BA, Master of Counseling,

Supervised by Maribel Rodriguez Laguna, MA, LPC-S

*Please note CPT codes will only be used for the purpose of your submission of reimbursement claims to your healthcare insurance provider*

A) Psychiatric Diagnostic Evaluation (50 mins) CPT 90791 = $110

B) Telehealth Psychiatric Diagnostic Evaluation (50 mins) CPT 90971GT = $110

C) Individual Psychotherapy (50 mins) CPT 90837 =$100

D) Telehealth Individual Psychotherapy (50 mins) CPT 90837GT =$100

G) Psychotherapy for Crisis (50 mins) CPT 90839=$100

H) Telehealth Psychotherapy for Crisis (50 mins) CPT 90839GT=$100

I) Prolonged service in an outpatient setting (EMDR Intensive - 180 ins) CPT 99354 = $300

Other Services and Fees

*These Fees are not eligible for discounts or sliding scale and due to the unpredictable nature of each client’s needs will not be included in the GFE. This information serves as notice of additional fees you may incur based on your personal needs* A) Unscheduled/Ad-Hoc/Crisis/Parent Consultation Phone Calls > 15 mins= prorated @ $35/15 mins B) Requested Documentation to Include Treatment Summary, Other Provider Consultation, Superbill, Other Written Letters =prorated @ $100/1hr C) No Call No Show to Scheduled Appointment (as defined in the informed consent)- $110 for the intake session and $100 for each follow up session. D) Cancelled Appointment less than 48 Hours before appointment (without same- week reschedule, as defined in your informed consent) = $110 for the intake session and $100 for each follow up session.

Personal Cost Estimation

For Individual therapy, your current fee per session is: $110 for the intake session and $100 for each follow up session. You are currently scheduling sessions weekly. Based on a 52-week calendar year, your total estimated cost of treatment, not including holidays, breaks, and other unpredictable fees/services disclosed above, will be $5,210. If you are seeing your provider biweekly, your total estimated cost of treatment per 52 week year would be 2,610. If you are seeing your provider monthly, your total estimated cost of treatment per 52 week year would be $1,210.