Good Faith Estimate (GFE) Notice

You have the right to receive a "Good Faith Estimate" explaining how much your mental health care will cost. This notice explains your rights, how estimates are determined at Paper Moon Counseling, and how to dispute a bill if actual charges exceed your estimate.

1. Who Receives a Good Faith Estimate?

A Good Faith Estimate is provided to any client who is:

• Uninsured: You do not have commercial or public health insurance coverage.
• Self-Pay (Opt-Out): You have health insurance, but choose not to use your insurance benefits for therapy (e.g., for privacy reasons, out-of-network status, or high-deductible plan preference).

Note: If you are using an in-network insurance plan (Aetna, BlueCross BlueShield of NC, UnitedHealthcare, or NC State Health Plan), your out-of-pocket costs (copayments, coinsurance, and deductibles) are determined directly by your insurance carrier rather than a Good Faith Estimate.

2. Standard Self-Pay Fee Schedule

At Paper Moon Counseling, pricing is straightforward and transparent. We do not have hidden facility fees or administrative charges.

3. How Your Estimate Is Calculated

Mental health therapy is individualized. The total cost of therapy depends on your unique clinical needs, goals, and how frequently we meet:

• Initial Session: Every new client begins with one comprehensive diagnostic intake session ($215).
• Ongoing Cadence: Most clients begin with weekly or bi-weekly 50–60 minute sessions ($180 per session).
• Example Estimate (12 Weeks): For a client attending 1 intake session plus 11 ongoing weekly sessions, the total estimated cost for a 12-week course of therapy would be $2195 ($215 + $1,980).
• Collaborative & Voluntary: We review your treatment goals and frequency collaboratively throughout your care. You are never locked into a contract and have the right to pause, adjust frequency, or discontinue therapy at any time without penalty.

4. When You Will Receive Your Written GFE

Prior to your first appointment, you will receive a formal written Good Faith Estimate document in your secure client portal (TherapyPortal) within the required federal timeframes:

• If your appointment is scheduled at least 3 business days in advance: within 1 business day of scheduling.
• If your appointment is scheduled at least 10 business days in advance: within 3 business days of scheduling.
• You may also request a Good Faith Estimate at any time before scheduling an appointment.

5. Your Right to Dispute a Bill

If you receive a bill from Paper Moon Counseling that is at least $400 more than your Good Faith Estimate, you have the legal right to dispute the bill under federal law.

6. More Information

For questions or more information about your rights under the No Surprises Act, visit the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov/nosurprises or call the federal No Surprises Help Desk at 1-800-985-3059.