Mindful Madison Psychotherapy, LLC
PO Box 294, Stoughton, WI 53589
(608) 444-5106
Good Faith Estimate for Health Care Items and Services
This Good Faith Estimate for Health Care Items and Services is provided when you pay for mental health services at Mindful Madison Psychotherapy LLC without insurance. You are provided this estimate per the No Surprises Act, which includes an estimated session cost that is effective through December 31st of the calendar year it was issued. A new good faith estimate may be requested at the start of the new calendar year with the updated psychotherapy rate for the type of services you are requesting.
Type of Service
☐ Individual Therapy – Individual one-on-one psychotherapy with a therapist either in person or held virtually for 50-55 minutes.
☐ Couples Therapy – Relationship therapy consists of the members of a relationship meeting with a therapist either in person, or virtually for 60 minutes. Some sessions may be held with one member of the relationship to discuss their personal experience with the relationship, as agreed upon with your therapist. Couples therapy rate applies to all sessions regardless of the number of attendees.
☐ Group Therapy – Group therapy takes place in a setting with multiple participants, either in person or held virtually. Group therapy typically is scheduled for 90 minutes or two hours, depending on the type of group. Group therapy typically is centered around a theme or topic all members can benefit from.
Summary of Expected Charges
| Therapy Type | Cost per Session |
| ☐ Individual Therapy (90837) with Tim Fredrickson, MS MA LPC | 150.00 |
| ☐ Couples Therapy (90847) with Tim Fredrickson, MS MA LPC | 185.00 |
| ☐ Group Therapy (90853) with Tim Fredrickson, MS MA LPC | 60.00 |
Total Estimated Cost
Total annual estimated costs depend on how often you choose to attend therapy. Frequency should be discussed with your therapist. Typically, therapists see clients at most, once per week, unless a person is experiencing a life event in which they request extra support. The duration of your therapeutic relationship will depend on your goals, progress, and overall general state of mental well-being. A client can “reasonably expect” to be able to attend therapy until their goals are met, they choose to discontinue service, or their therapist has opted to end the therapeutic relationship. Estimated costs are valid for the calendar year ending on December 31st.
Examples of Estimated Cost
Typically, there are 50 “weekly” sessions offered per year (to account for vacations and holidays). A person opting for bi-weekly therapy can expect 26 sessions per calendar year.
☐ If an individual attends therapy weekly for an entire calendar year, they can expect an annual maximum cost of $7500.
☐ If an individual attends therapy bi-weekly for an entire calendar year, they can expect an annual maximum of $3900.
☐ Couples therapy can expect an annual maximum of $9250 for weekly therapy, and $4810 for bi-weekly therapy.
☐ Group therapy runs for a fixed period of time, ranging from 6 to 16 weeks. An individual attending weekly group therapy for a period of six weeks could expect to pay $360, while a 16-week program would cost $960.
General Disclaimers
The good faith estimate shows the costs of items and services that are reasonably expected for your health care needs during one calendar year. The estimate is based on information known at the time the estimate was created. To respect your privacy, diagnostic information is not provided on this document, unless a modification is made to the above noted session types.
The good faith estimate does not include any unknown or unexpected costs that may arise during treatment. Additional services may be recommended as part of the course of treatment that are scheduled separately are not reflected in this good faith estimate. These services may be scheduled with external mental health providers.
Information provided in this document is only an estimate and the actual services or charges may differ from this estimate. This estimate does not require you, as the client, to obtain psychotherapy or other services from Mindful Madison Psychotherapy, LLC.
Services may also be held virtually if both parties are in the state of Wisconsin, or the client is in the state of South Carolina. If you require a diagnosis code, please contact your provider for specifics.
Provider / Facility Information
Mindful Madison Psychotherapy, LLC
Mental Health Clinic
PO Box 294, Stoughton, WI 53589
MindfulMadisonTherapy@gmail.com
(608)444-5106
Service Location: 660 W Washington Ave, Madison, WI
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers, health care facilities, and providers of air ambulance services are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a group health plan or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals) or not seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals) in writing(and may also provide it orally, if an uninsured (or self-pay) individual requests a good faith estimate in a method other than paper or electronically), upon request or at the time of scheduling health care items and services.
You may start a dispute resolution process with the U.S. Department of Health and Human Services within 120 days of the original bill. The government charges $25 to start the process. More information can be found at http://www.cms.gov/nosurprises.
