Mariemont Center Building

3914 Miami Road, Suite #301

Mariemont, Ohio 45227

Your appointment is conducted online through a HIPAA-compliant platform that you can access with your computer, tablet, or smartphone.

Yes

Individual therapy/$150 (55 min)

Child therapy/$130 (45 min)

Couples therapy/$200 (55 min)

Coaching/$150 (55 min)

A credit card will be kept on file and you will be charged on the day of your appointment.

"No Surprise Act" Good Faith Estimate

You are entitled to receive a Good Faith Estimate of what the charges could be for psychotherapy services provided to you. While it is not possible for a provider to know in advance how many sessions you will need, this form provides an estimate of the cost of services provided.

An estimate of frequency of visits and length in therapy will not be determined until your concerns are evaluated and will also vary based on the progress that you make, which depends in part on your efforts with the process. Your total cost of services will depend upon the number of sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

Disclaimer

A Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. This estimate is not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. There may be additional items or services recommended as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. You have the 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 may contact Katie Burchenal Counseling to let Katie know the billed charges are higher than the Good Faith Estimate. You can ask Katie to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the qualityof the services furnished to you.

I am not in-network with any insurance companies. With PPO insurance plans, I am considered an out-of-network provider and you may be reimbursed in full or in part. I can provide you with a monthly superbill to give to your insurer. Please check your coverage by asking the following questions:

* Does my plan provide out-of-network reimbursement for mental health?

* Is there a deductible I need to meet before you will start to reimburse me?

* How many sessions per year does my health insurance cover?

* What percentage of the fee do you cover?

If you’re unable to make it to a session, you must cancel at least 24 hours in advance. If you cancel with less than 24-hours notice, you will be responsible for the full cost of the session. I understand life/emergencies happen and am as flexible as possible to accommodate for this.

You can reach me by phone at 513.520.3712, or email: katie@katieburchenalcounseling.com

I share a blended family with my husband and our eight children. I love to visit my kids and family who live out of town. Some of my favorite activities include attending sporting events and spending time outdoors.