NEW CLIENT GOOD FAITH ESTIMATE

* You are entitled to receive this “Good Faith Estimate” of your potential charges 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 valid for 12 months. 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. PLEASE INITIAL BELOW TO INDICATE UNDERSTANDING OF THIS STATEMENT.

* Ampaw Psychotherapy and Consulting LLC provides individual, couples, and family psychotherapy, virtually and in person to clients who are located in the state of Colorado. Ampaw Psychotherapy and Consulting also provides individual, couples, and family coaching and professional (educational consulting services regarding curriculum development and educational best practices to professionals nationwide. PLEASE INITIAL BELOW TO INDICATE UNDERSTANDING OF THIS STATEMENT.

* Date of Good Faith Estimate:

Provider Estimate

Provider name: Josephine Ampaw, LSW, MFTC, MA
Provider/facility type: Ampaw Psychotherapy and Consulting LLC (Private Practice Outpatient Treatment)
Street address: 8751 E Hampden Avenue STE B-9, Denver, CO 80231
City: Denver
State: Colorado
ZIP code: 80231
Contact person: Josephine Ampaw
Phone: 719-647-7855
Email: josephine@ampawpc.com

Patient Information

* Patient

First name:

Middle name:

Last name:

Date of birth:

* Patient Contact Information

Street or PO box:

City, state, ZIP:

Phone number:

Email address:

Patient's contact preference:

* Services Requested

Individual Therapy (45 minutes)

Individual Therapy (55-60 minutes)

Individual Therapy (90-120 minutes)

Couples Therapy (55-60 minutes)

Couples Therapy (90-120 minutes)

Family Therapy (45 minutes)

Family Therapy (55-60 minutes)

Family Therapy (90-120 minutes)

Individual Coaching(45, 55-60, 90-120 minutes)

Couples Coaching (45, 55-60, 90-120 minutes)

Family Coaching (45, 55-60, 90-120 minutes)

* Patient Diagnosis

Patient primary diagnosis:

Patient secondary diagnosis:

If scheduled, list the date(s) the Primary Service or Item will be provided, Leave Blank to Indicate that the service or item is not yet scheduled:

The following is a detailed list of expected charges. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.

Primary service or item:

Scheduled dates of service:

* Provider Estimates at One Session Per Week

Ampaw Psychotherapy and Consulting LLC estimated total cost(1 session):

Ampaw Psychotherapy and Consulting LLC estimated total cost ((4 sessions):

Ampaw Psychotherapy and Consulting LLC estimated total cost (8 sessions):

Ampaw Psychotherapy and Consulting LLC estimated total cost (12 sessions):

NA

Provider Estimates at Two Sessions Per Week(If previously discussed)

Ampaw Psychotherapy and Consulting LLC estimated total cost(2 sessions):

Ampaw Psychotherapy and Consulting LLC estimated total cost(8 sessions):

Ampaw Psychotherapy and Consulting LLC estimated total cost(16 sessions):

Ampaw Psychotherapy and Consulting LLC estimated total cost(24 sessions):

NA

Additional health care provider/facility notes:

Disclaimer

* You have a right to initiate a dispute resolution process with U.S Department of health and human services (HHS) if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). If you choose to utilize this dispute option, you will be required to submit your claim within 120 calendar days from the date of your first bill. There is a $25 fee to utilize HHS dispute process. If the agency reviewing your claims agrees with you, you will have to pay the price of the good faith estimate. If the agency disagrees with you and agrees with your health care provider, you will be required to pay the full 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. ispute process, visit www.cms.gov/nosurprises or call (800) 368-1019. 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. PLEASE INITIAL TO INDICATE UNDERSTANDING OF THIS STATEMENT.