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  • In compliance with the No Surprises Act (effective January 1, 2022), we are notifying you of expected costs for services provided.  You have a right to know and are protected from “surprise billing.”  Specifically, we are notifying you of expected costs for PeoplePsych therapy services, as you are opting to receive services from us under one or all of the of the following 3 conditions: 

     

    1.     We are not “In-network” with your insurance

    2.     You are not insured by a contracted payor for the services rendered

    3.     You elect not to use insurance coverage for services requested and provided.

     

    The No Surprises Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.

     

    Additionally, we are required to provide you with a Good Faith Estimate of the cost of services. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, we wish to confirm your therapist’s current fee schedule is:

     

    •       Initial Session – Individual Therapy:  $175

    •       Initial Session – Couples/Family Counseling:  $190

    •       Subsequent Session – Individual Therapy:  $150

    •       Subsequent Session – Couples/Family Counseling:  $165    

     

    The charges listed above are the maximum charges per scheduled session.  You and your therapist (with the approval of PeoplePsych) may have agreed on a lower rate per session, which is what you will be charged. Your therapist will collaborate with you on a regular basis to determine how many sessions you may need and document any approved discount for services.

  • It is a federal requirement that you sign this form to begin/resume treatment. Please sign and date before your next appointment.  If you do not wish to sign electronically you can email or fax the signed form to PeoplePsych directly:  intake@peoplepsych.com or 312-448-7218.

     

    By signing below, I certify that I understand and accept the terms described above.

     

    Signature of Responsible Party:

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