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Good Faith Estimate
For Clients who are self-pay and not using insurance

Notice: ​You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

​Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit or call ​800-985-3059.

Riverscape Counseling Good Faith Estimate


​Beginning January 1, 2022, federal laws regulating client care have been updated to include the “No Surprises” Act. Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services called a “Good Faith Estimate” (GFE) explaining how much your medical care will cost.

This new regulation is designed to provide transparency to patients regarding their expected medical expenses and to protect them from surprises when they receive their medical bills. It allows patients to understand how much their health care will cost before they receive services.

There are a number of factors that make It challenging to provide an estimate on how long it will take for a client to complete therapeutic treatment, and much depends on the individual client and their goals in seeking therapy. Some clients are satisfied with a reduction in symptoms while others continue longer because it feels beneficial to do so. Others begin to schedule less frequently, and may continue to come in for “tune ups” or when issues arise. Ultimately, as the client, it is your decision when to stop therapy.

​At Riverscape Counseling, we must provide a diagnosis for all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act".   A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update the GFE. It is within your rights to decline a diagnosis per state and federal guidelines. 

​Common Diagnosis Codes at Riverscape Counseling.

Below are common diagnosis codes at Riverscape Counseling; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns.

  • Adjustment Disorder (F43.23)

  • Mental Disorder, Not Otherwise Specified (F99)

  • Depression (F32.9)

  • Anxiety (F41.1)

  • Bipolar (F31.9)

  • PTSD/Post Traumatic Stress Disorder (F43.10)

​Riverscape Counseling recognizes every client's therapy journey is unique. 
How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including

  • Your schedule and life circumstances

  • Therapist availability

  • Ongoing life challenges

  • The nature of your specific challenges and how you address them

  • Personal finances

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

​According to the American Psychological Association, “on average 15 to 20 sessions are required for 50 percent of patients to recover as indicated by self-reported symptom measures”. Additionally, they state that through the working relationship between the client and counselor sometimes the preference is for “longer periods (e.g., 20 to 30 sessions over six months), to achieve more complete symptom remission and to feel confident in the skills needed to maintain treatment gains”.  

So, it depends on several factors because everyone has unique counseling goals. Like any other relationship, it takes time to develop a therapeutic relationship with your counselor and identify your treatment goals, establish a plan of action, and work towards accomplishing them. Whatever your number of sessions will be, we will work together to meet your needs.  


​Common Services at Riverscape Counseling

  • 90791: Intake session ($195)

  • 90834: 38-52 minute psychotherapy session ($140) 

  • 90847/46: Family/Couples psychotherapy session ($175)   

  • 90837: 53+ minute extended psychotherapy session ($165) 

  • 90832: 16-37 min session ($86)

  • 90853: Group therapy session ($52)

Where services will be delivered. 

  • Riverscape Counseling provides services  In - Office office and via Telehealth.


Riverscape Counseling office locations

  • 11 W Monument Ave Suite 100 Dayton , Oh 45402

  • 761 Miamisburg -Centerville Rd Dayton Oh 45458 

  • 1455 N Pennsylvania St Indianapolis IN 46202

  • 5224 Dearth rd Springboro , Oh  45066


Provider Information

  • Provider Name: Darcie R Clark LPCC LLC  (dba Riverscape Counseling), NPI- 1669842258  Email: Phone #: 937-319-4448



Good Faith Estimate

​For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, we will only quote weekly appointments.

90791: Intake session ($195) plus 90847/46: Family/Couples psychotherapy session ($175) for 51 weeks: $9120
90791: Intake session ($195) plus 90837: 53+ minute extended psychotherapy session for 51 weeks ($165): $8610
90791: Intake session ($195) plus 90832: 16-37 minute psychotherapy session ($86) for 51 weeks: $4581

90791: Intake session ($195) plus 90853: Group therapy session ($52) for 51 weeks: $2847

The above examples are provided to give an idea of the financial expectations for a calendar year. The frequency and duration is dependent on your individual needs and goals.

We look forward to talking with you and answering any questions you may have about the “No Surprises” Act and Good Faith Estimates.

​Good Faith Estimate Disclaimer

  • This Good Faith Estimate shows the costs of items and services that are reasonably expected for your 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. 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 us at or call 937-319-4448 to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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. 

  • To learn more and get a form to start the process, go to or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.


Public disclosure of the “Good Faith Estimate

Riverscape Counseling has always provided transparency in our billing practices by displaying our fee schedule within our Counseling Policies. Please know that the Good Faith Estimate does not change any agreements you have already made with us with regard to self pay. Your review of this form and signature will be required so that we can demonstrate our compliance with the mandate. Thank you!

​If you have questions or concerns about the Good Faith Estimate or the No Surprises Act, please reach out to us at 937-319-4448 or email us at

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