Good Faith
Estimate
GOOD FAITH ESTIMATE
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any client who is uninsured or who insured but does not plan to use their insurance benefits to pay for health care items and/or services.
The Good Faith Estimate works to show the cost of items and services that are reasonable expected for your mental health care needs for an item or service. 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 (e.g. missed appointment fees, legal fees, etc.).
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 upon the initiation of psychotherapy, 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, as well as miscellaneous items like missed appointment fees, 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.
Effective Nov. 1, 2025:
The fee for an initial diagnostic assessment/intake appointment is $270 (CPT Code 90791) for master's level providers. PhD/PsyD level providers will be more. Christine Osgood charges $250 for diagnostic assessment/intake appointment.
The fee for a traditional 55-minute psychotherapy session (in-person or via telehealth) is $225 (CPT Code 90837) for master's level providers. PhD/PsyD level providers will be more. Christine Osgood charges $200 per 55-minute session.
You may project any potential future cost(s) by multiplying the session fee of $200 by the total number of sessions, after the initial intake. This will result in your total estimated cost for mental health service(s).
For example, if you had 4 sessions with Christine after your initial intake session: $250 for first/intake session + $200 session fee x 4 sessions =$1050
If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment. Many clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may differ, depending upon your individual needs and preference. Similarly, if you have a shorter or longer session (than the standard 55 minutes), then the costs will also differ. It is important, when determining your total estimate, to take into consideration vacations, holidays, emergencies, and sick time.
Clients who have a Sliding Fee Scale Agreement with their counselor may be provided a lower rate than reflected in the above examples.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them 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 (DHS). 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, please visit www.cms.gov/nosurprises. (Valid for 12 months from signature date)
This Good Faith Estimate is provided by:
Wellspring Group
NPI2: 1609114883
EIN: 26-4257525
Providers:
Dr. Kim Anderson – NPI: 1891249140
Sarah Bordeleau – NPI: 1528733896
Pamela Bull – NPI: 1205283611
Amanda Cornelius – NPI: 1942593561
Esther Davis – NPI: 1912534280
Jared Hibma – NPI: 1780988360
Brittany Kiel – NPI: 1841538535
Lisa Medin – NPI: 1790416709
Christine Osgood - NPI: 1386519965
Megan Rustad - NPI: 1497467906
Lisa Wold – NPI: 1467600304
Services will be provided by telehealth or in-person at:
1403 Silver Lake Road, Suite 2
New Brighton, MN 55112
or
8170 Old Carriage Court, Suite 200
Shakopee, MN 55379
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You will sign and date a copy of this Good Faith Estimate as part of your initial paperwork.