GOOD FAITH ESTIMATE

Notice and Consent for Balance Billing Protection

Therapy with Akilah, LLC
Akilah J. Pierre, LMFT
5049 Copley Road
Philadelphia, PA 19144
Phone: 610-227-5071
Email: akilah@therapywithakilah.com
NPI (Individual): 1154957686
NPI (Group): 1346120250

ABOUT THIS GOOD FAITH ESTIMATE

You have the right to receive a "Good Faith Estimate" explaining how much your medical and mental health care will cost.

Under the federal No Surprises Act, healthcare providers are required to give uninsured and self-pay patients an estimate of expected charges before services are provided.

This Good Faith Estimate shows:

  • The expected cost of therapy services

  • What you may be charged if you continue treatment

  • Your rights and protections under federal law

This estimate applies to:

  • Clients who do NOT use insurance to pay for services (self-pay/private pay)

  • Clients whose insurance is out-of-network (not contracted with us)

  • Clients who choose not to use their insurance

This estimate does NOT apply to:

  • Clients using in-network insurance benefits

YOUR RIGHTS UNDER THE NO SURPRISES ACT

You have the right to:

✅ Receive a Good Faith Estimate of expected charges before receiving services or upon request

✅ Receive an updated estimate if the scope of services changes significantly

✅ Dispute charges if your final bill is significantly higher than the Good Faith Estimate (by $400 or more)

✅ Ask questions about the estimate and charges at any time

✅ Choose to use insurance instead of self-pay (if you have insurance coverage)

IMPORTANT INFORMATION ABOUT THIS ESTIMATE

This is an ESTIMATE, not a contract or final bill.

Your actual charges may differ if:

  • The scope of treatment changes (e.g., more or fewer sessions than estimated)

  • Your clinical needs change

  • Additional services become necessary

  • You miss sessions or cancel without adequate notice

  • Sessions run longer than 50 minutes (with your consent)

This estimate is based on:

  • The information you provided during your initial consultation or intake

  • Standard treatment for the concerns you described

  • Expected session frequency (weekly or biweekly)

  • Our current fee schedule

This estimate does NOT include:

  • Services provided by other healthcare providers

  • Fees for no-shows or late cancellations

  • Additional services you may request (e.g., letters, forms, extended sessions)

  • Changes in fees (you will be notified 30 days in advance of any fee changes)

ESTIMATED COSTS FOR THERAPY SERVICES

STANDARD SESSION FEES

  • Individual Therapy (Private Pay) $130 - 50 minutes
  • Individual Therapy (Sliding Scale) $90–$115 - 50 minutes
  • Initial Consultation FREE - 20 minutes

ESTIMATED TOTAL COST BASED ON TREATMENT DURATION

The following estimates assume weekly therapy sessions at the standard private pay rate of $130 per session.

If you are using the sliding scale, calculate based on your agreed-upon rate ($90–$115 per session).

SHORT-TERM THERAPY (8–12 sessions / 2–3 months)

Estimated number of sessions: 8–12 sessions
Estimated cost range: $1,040–$1,560
Typical timeframe: 2–3 months of weekly therapy

Who this is for:

  • Clients working on specific, focused issues

  • Clients who have prior therapy experience

  • Clients seeking skill-building or brief intervention

MODERATE-TERM THERAPY (13–26 sessions / 3–6 months)

Estimated number of sessions: 13–26 sessions
Estimated cost range: $1,690–$3,380
Typical timeframe: 3–6 months of weekly therapy

Who this is for:

  • Most clients seeking generational growth therapy

  • Clients working on family patterns and self-love development

  • Clients needing sustained support for lasting change

This is the most common treatment length for our clients.

LONG-TERM THERAPY (27+ sessions / 6+ months)

Estimated number of sessions: 27–52 sessions
Estimated cost range: $3,510–$6,760
Typical timeframe: 6–12 months of weekly therapy

Who this is for:

  • Clients working on deeply rooted patterns

  • Clients who prefer ongoing therapeutic support

  • Clients who benefit from long-term relational therapy

BIWEEKLY SESSIONS

If you attend therapy every other week instead of weekly, adjust the estimates accordingly:

  • 3 months - 6 sessions $780 (Private Pay)
  • 6 months - 12 sessions $1,560 (Private Pay)
  • 12 months - 24 sessions $3,120 (Private Pay)

SLIDING SCALE ESTIMATES

If you are approved for sliding scale pricing ($90–$115 per session), your estimated costs will be lower:

  • 8 sessions - $720 to $920
  • 12 sessions - $1,080 to $1,380
  • 26 sessions - $2,340 to $2,990
  • 52 sessions - $4,680 to $5,980

ADDITIONAL FEES (IF APPLICABLE)

The following fees are NOT included in the standard session cost and will be charged separately if applicable:

  • No-Show Fee - Full session fee ($130) | If you miss a session without notice
  • Late Cancellation Fee - Full session fee ($130) | If you cancel with less than 7 days' notice
  • Extended Session (beyond 50 min) - Prorated fee ($65 per additional 30 min) | Only with prior agreement for extended sessions
  • Letter Writing (e.g., ESA letter, work accommodation) - $50 to $150 | If you request written documentation
  • Records Request (copies of clinical records) - $25 to $50 | If you request copies of your full clinical record

Note: Most clients never incur additional fees. These only apply in specific circumstances.

WHAT IS NOT COVERED BY THIS ESTIMATE

This Good Faith Estimate does NOT include:

❌ Services provided by other healthcare providers (psychiatrists, medical doctors, etc.)
❌ Prescription medications
❌ Emergency services (if you go to an emergency room or crisis center)
❌ Services provided outside of therapy sessions (unless specifically agreed upon)
❌ Court-related services (we do not provide forensic evaluations or testimony)
❌ Services not related to your mental health treatment

FACTORS THAT MAY CHANGE YOUR COSTS

Your actual costs may be higher or lower than this estimate, depending on:

Factors that may INCREASE costs:

  • Attending therapy more frequently than estimated (e.g., weekly instead of biweekly, or multiple sessions per week)

  • Continuing therapy longer than initially estimated

  • Missing sessions or canceling without adequate notice (late cancellation/no-show fees)

  • Requesting additional services (letters, extended sessions, phone consultations)

Factors that may DECREASE costs:

  • Attending therapy less frequently than estimated

  • Completing therapy in fewer sessions than estimated

  • Qualifying for sliding scale pricing

  • Using insurance (if you decide to file a claim with out-of-network benefits)

HOW TO KEEP COSTS PREDICTABLE

To avoid unexpected charges:

✅ Attend your scheduled sessions (or cancel with adequate notice)
✅ Communicate with your therapist if your financial situation changes
✅ Ask questions about fees before requesting additional services
✅ Keep your payment method up to date to avoid late payment fees
✅ Review your invoices and contact us immediately if you have questions

IF YOU HAVE INSURANCE

If you have health insurance but choose to self-pay:

  • You may be able to submit a superbill to your insurance company for out-of-network reimbursement

  • We can provide a superbill (detailed receipt) after each session

  • Reimbursement rates vary widely by insurance plan

  • You are responsible for the full session fee upfront, regardless of whether your insurance reimburses you

To check your out-of-network benefits, ask your insurance company:

  • "What is my out-of-network mental health coverage?"

  • "What percentage do you reimburse for out-of-network therapy?"

  • "Do I need to meet a deductible first?"

  • "Is there a limit on how many sessions are covered per year?"

If we are in-network with your insurance:

  • This Good Faith Estimate does NOT apply

  • You will pay your copay as determined by your insurance plan

  • Your insurance company determines what they will pay

YOUR RIGHT TO DISPUTE CHARGES

If your final bill is at least $400 MORE than this Good Faith Estimate:

You have the right to dispute the bill through a federal process called patient-provider dispute resolution.

Steps to dispute:

  1. Contact us first within 120 days of receiving the bill that is higher than expected

  2. Try to resolve the issue directly - we may be able to explain the charges or adjust the bill

  3. If we cannot resolve it, you can initiate the federal dispute resolution process

To start the federal dispute resolution process:

The dispute resolution process:

  • Is conducted by an independent third party

  • Typically takes 30-60 days

  • Costs $25 to file (you may get this fee back if you win)

  • Results in a binding decision

You must initiate the dispute within 120 calendar days of the date on the bill.

QUESTIONS ABOUT YOUR ESTIMATE

You have the right to ask questions at any time about:

  • How this estimate was calculated

  • What services are included

  • Why your actual charges differ from the estimate

  • Payment options or financial assistance

To ask questions or request an updated estimate:

WHEN YOU WILL RECEIVE THIS ESTIMATE

You will receive a Good Faith Estimate:

✅ Before your first session (after your free consultation, if you decide to move forward with therapy)

✅ Upon request (you can ask for an updated estimate at any time)

✅ If the scope of treatment changes significantly (e.g., we discuss increasing or decreasing session frequency)

You will receive the estimate:

  • Via email (sent through SimplePractice)

  • At least 1 business day before your first scheduled session

  • Or within 3 business days if you schedule a session less than 10 days in advance

CONTACT INFORMATION

Questions about this Good Faith Estimate or your charges?

Akilah J. Pierre, LMFT
Therapy with Akilah, LLC
5049 Copley Road
Philadelphia, PA 19144

Email: akilah@therapywithakilah.com
Phone: 610-227-5071
Website: www.therapywithakilah.com

MORE INFORMATION ABOUT YOUR RIGHTS

For more information about your rights under the No Surprises Act:

To file a complaint about surprise medical bills: