Good Faith Estimate

Provider Information:

Provider Name: Suzanne Skeete Benites, LCSW/TheraThrive LLC
Provider License #: Texas 61995; Colorado: Colorado License No. CSW.09927477
Provider Address: 602 Strada Circle, Suite 102
Mansfield, Texas 76063
Provider Telephone #: 817-482-9905
Provider email: SuzanneBenitesLCSW@thera-thrive.com
Provider NPI: 1851870034
Provider EIN: 84-2155198

Primary Service or Item Requested/Scheduled: Psychotherapy Services

Primary Diagnosis and Diagnosis code: to be determined at scheduled intake appointment.

Good Faith Estimate:

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

Schedule of Fees:

The following is a detailed list of TheraThrive LLC / Suzanne Skeete Benites, LCSW psychotherapy and other service charges when paying cash for services. The estimated costs are valid for 12 months from the date of the Good Faith Estimate. Provider Estimate below does not include-late cancellation/no show fees, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees. Length of session depends upon diagnosis, severity, and modality type.

Psychotherapy:

00000 ~ Initial Consultation 15 minutes - $0.00
90791 ~ Intake Session - Individual 60-90 minutes - $175.00
90837 ~ Individual Psychotherapy, 60 minutes - $150.00
90834 - Individual Psychotherapy, 45 minutes - $125.00

Late Cancel Fee-provider requires 24 hours notice of cancellation to avoid a late cancel fee charge for the full fee of your session. See Suzanne Skeete Benites, LCSW/TheraThrive, LLC informed Consent for further details regarding late cancel fee policy.

Trial, Court Ordered Appearances, Litigation: $250.00 per hour to include travel time, court time and preparation time.

Copies of medical records are .25 cents per page

Bank return fees: $25.00

Estimated charges for recurring psychotherapy services:

The fee for a 60 minute psychotherapy visit (in person or via telehealth) is $150.00. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on a fee of $150.00 per visit, the following are expected charges of psychotherapy services:

1 week of Service = $150.00

13 weeks of Service (approx. 3 months) = $1,950

26 weeks of Service (approx. 6 months) = $3,900

39 weeks of Service (Approx. 9 months) = $5,850

52 Weeks of Service (Approx. 12 months) = $7,800

The fee for a 45 minute psychotherapy visit (in person or via telehealth) is $125.00. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on a fee of $125.00 per visit, the following are expected charges of psychotherapy services:

1 week of Service = $125.00

13 weeks of Service (approx. 3 months) = $1625

26 weeks of Service (approx. 6 months) = $3,250

39 weeks of Service (Approx. 9 months) = $4875

52 Weeks of Service (Approx. 12 months) = $6,500

DISCLAIMER:

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.

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, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

To learn more and get a form to start the process, go to
www.cms.gov/nosurprises/consumers or call 1-800-985-3059.