Where services will be rendered:
In-person: 8 Myrtle Avenue, Westport, CT, 06880
Online: Through a secure, HIPAA-compliant video-based platform

You are entitled to receive this “Good Faith Estimate” of what the charges could be per session for psychotherapy or dietary services provided to you. While it is not possible for a psychotherapist or dietitian to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services rendered that are provided per session. Your total cost of services will depend upon the number of sessions you attend, your individual circumstances, and the type and/or 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 visits. Most clients will attend one psychotherapy or dietary visit per week, but the frequency of psychotherapy or dietary visits that are appropriate in your case may be more or less than once per week, depending upon your needs. 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.

Common services and service codes used at Lift Wellness Group, LLC for individual therapy include:
00000: 20-minute consultation
90791: Initial therapy intake assessment—60- minutes
90834: Individual therapy session; recurring—45-minutes

Charge per 1 individual psychotherapy session is as follows:

Initial individual intake session - $250.00
Individual follow-up session - $200.00

Charge per 1 individual dietary session as follows:

Initial 60- minute individual intake session - $250.00
Individual 30-minute follow-up session - $175.00

At Lift Wellness Group, LLC, a client is not diagnosed until a client has been seen for an initial intake session, and after 3 follow-up sessions have been completed. Clients are not typically diagnosed until the therapist or dietitian believes a specific diagnosis to be accurate after a mental health evaluation with the client has been completed, and only if it is in the client's best interest to receive a mental health diagnosis. Instead of using diagnostic codes, Z codes are used which represent general areas of concerns to be addressed in therapy. Please speak to your therapist about this practice if you have any questions or concerns.

Common diagnostic codes used at Life Recovery Counseling, LLC:
F43.20 Adjustment Disorder, Unspecified
Z13.30 Encounter for screening examination for mental health and behavioral disorders, unspecified
Z71.9 Counseling, unspecified
Z91.49 Other personal history of psychological trauma, not elsewhere classified

You have a right to initiate a dispute resolution process 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 per services rendered).

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.