Cooper & Cooper Mental Health Group, PLLC
Doing business as River Valley Therapy Co.

Effective Date: 12/12/25

Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your mental health care will cost.

This estimate is for individuals who do not have insurance or who choose not to use insurance for services.

Your Right to a Good Faith Estimate

You have the right to receive a written Good Faith Estimate of the expected cost of mental health services before services are provided.

This estimate shows the costs of items and services that are reasonably expected for your care. It is not a contract and does not require you to receive services.

Actual charges may differ based on your clinical needs, frequency of sessions, or changes in treatment planning.

Services Covered by This Estimate

A Good Faith Estimate may include expected charges for:

Psychotherapy sessions
Diagnostic assessments
Clinical documentation and treatment planning
Telehealth or in-person sessions
Care coordination when clinically indicated

You may request a Good Faith Estimate at any time prior to or during treatment.

Example Estimated Costs

The following is an example only. Your individual estimate will be provided separately.

Initial intake or diagnostic session:
Estimated cost: $___ to $___

Ongoing psychotherapy sessions:
Estimated cost per session: $___

Estimated frequency:
Weekly or biweekly, based on clinical need

Total projected cost over a 30-day period:
Estimated range: $___ to $___

Important Disclosures

This Good Faith Estimate:

Reflects expected costs at the time it is created
Does not include unexpected services that may arise
May change if your treatment needs change
Does not guarantee outcomes or number of sessions

You will be notified if there are significant changes to your estimated cost.

This Good Faith Estimate applies only to self-pay services or services not billed through insurance.

Clients using insurance should contact their insurance carrier for information about deductibles, copayments, and coverage.

If Your Bill Is Higher Than Your Estimate

If you receive a bill that is at least four hundred dollars more than your Good Faith Estimate, you may have the right to dispute the bill.

You may initiate a dispute through the federal patient provider dispute resolution process.

More information is available at:

www.cms.gov/nosurprises

Or by calling:

1-800-985-3059

Questions or Requests

You may request a Good Faith Estimate or ask questions at any time by contacting:

River Valley Therapy Co.
Cooper and Cooper Mental Health Group PLLC
PO Box 1337
Greenwood, AR 72936
P: (479) 551-8420
F: (501) 426-8270
www.RVTherapyCo.com
Admin@RVTherapyCo.com