No Surprises Act

No Surprises Act: Good Faith Estimate

Provider Name: Jenna Johnston

NC License: 19467

SC License: 5433

UT License: 12050147-6004

Provider Mailing Address: 301 Government Center Drive Suite 200, Wilmington NC, 28403

Provider Phone #: (910) 877-8180

Provider NPI 1: 199214169    NPI 2: 1821731613

Services Requested:  Assessment, 60 Minute Psychotherapy

You are entitled to receive this “Good Faith Estimate” of what the charges could be 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 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.

The fee for Initial Assessment is $200. Thereafter, the fee for a 50 to 60 minute psychotherapy visit (in person or via Telehealth) is $150.  Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on a fee of $150 per visit, the following are expected charges of psychotherapy services:

Number of weeks and total estimated charges for 1 session per week (After Initial Assessment):

1 Week of Service $150

13 Weeks of Service (Approx. 3 Months) $1,950

26 Weeks of Service (Approx. 6 months) $3,900

39 Weeks of Service (Approx. 9 months) $5,850

52 Weeks of Service (Approx. 12 Months) $7,800

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).

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.