GOOD FAITH ESTIMATE
Pursuant to the No Surprises Act (HR133, Title 45 Section 149.610), this form is used to provide a current or prospective client with a
“Good Faith Estimate” (GFE)
of expected charges for services to be provided.
Provider Name Melissa Deaton Cook LPC, ACS, NCC, EXAT
VA License #:0701005208
PA License #PC005427
Provider Address: Suite D 206 Main St Dayton VA 22821
Provider Phone #: 540-416-1628
Provider Tax ID # 81-5321423
Provider NPI # 1205374055
Services Provided: Psychotherapy, Counseling
Pursuant to the No Surprises Act (HR133, Title 45 Section 149.610), this form is used to provide a current
or prospective client with a “Good Faith Estimate” (GFE) of expected charges for services to be provided.
If you have questions about this estimate, please contact us.
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 that may be recommended during treatment 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 a 30 to 60-minute psychotherapy visit (in person or via telehealth) is $215.00. 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 this per visit fee cited above,
the following are expected charges of psychotherapy services:
COST PER UNIT IS $215 PER 60 MIN
Number of Weeks
*Total estimated charges for 1 session per week
**Total estimated charges for x2 sessions per week.
01 Week of Service (Approx. 1 week) $215.00 *x2=$430
13 Weeks (Approx. 3 Months) $2795 x2=$5590
26 Weeks (Approx. 6 months) $5590 x2=$11,180
39 Weeks (Approx. 9 months) $8385 x2=$16770
52 Weeks (Approx. 12 Months) $11180 x2=$22360
Disclaimer
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected
services to address your mental health care needs. The estimate is based on the information known to us
when we did the estimate. The Good Faith Estimate does not include any unknown or unexpected costs that
may arise during treatment. You could be charged more if complications or special circumstances occur. If
this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good
Faith Estimate, you have the right to dispute the bill.You may contact the contact listed above if billed
charges are higher than the Good Faith Estimate. You can request an update to 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.
To learn more and get a form to start the process, go to:
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit
www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .
This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.
Client is responsible for payment at time of service. Spiral Roots LLC does not accept insurance or
Medicare payments. Client agrees not to admit any payments or bills to Medicare.
Revised 10/14/26