Disclaimer for the Estimate:

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created and is subject to change.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

The Good Faith Estimate is not a contract and does not require you to obtain the services from the provider identified on the Good Faith Estimate.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.

You will be given a copy to keep of the Good Faith Estimate when you become a client, keep it in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Under Section 2799B-6 of the Public Health Service Act, healthcare providers and healthcare facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services. Below is a good-faith effort to share potential costs with clients.

Molly Johnson, LMFT at Convergence Trauma Therapy, LLC operates with the understanding that not everyone who seeks therapy will meet diagnostic criteria. Therefore not everyone I see has a formal diagnosis. I have listed some diagnoses that clients I see often have.

• Adjustment Disorder Unspecified (F43.2)

• Posttraumatic Stress Disorder (F43.10)

• Posttraumatic Stress Disorder Chronic (F43.12)

Expected Charges

The length of treatment depends on a variety of factors (presenting concerns, diagnoses, desired frequency of sessions (weekly versus every two weeks), type of treatment being sought (short-term versus long-term), etc. Depending on the amount of progress we are able to make together, I typically meet with clients who are seeking short-term therapy for 3-9 months, and those seeking longer-term treatment, for 1-2 years or longer depending on their needs. Below are estimates for cost depending on services needed and length of time.

If you are seeking short-term therapy for a clear specific goal therapy may be between 3-9 months.

• If you come once a week at $250 per hour-long session your cost will be $3,000 for 12 hours to $9,000 for 36 hours.

• Due to the specialty of intensives, you get to determine the session length.

• If you come every other week at $500 per 2-hour session, your cost will be $6,000 for 12 two-hour long sessions (6 months) to $18,000 for 36 two-hour long sessions (18 months).

If you are seeking long-term therapy for more complex life situations therapy can be 1-2 years or more.