Provider Name: Borum and Associates LLC
License/#: MH10124
Provider Address: 4745 Old Hwy 37 Lakeland, Florida 33813
Provider Phone #: ( 863 ) 608 – 9392
Provider Tax ID#: 26-2699578
Provider NPI #: 1871920223
Services Requested: Counseling/psychotherapy

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 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.
The fee for a 50-minute individual psychotherapy visit (in-person or via telehealth) with a licensed
therapist is $125.00; the intake session is $150.00. The fee for a 50 minute individual session with a
registered intern therapist is $100.00 and the intake session is $125.00. The fee for a 50-minute couple’s
therapy session $150.00 and the intake session is $175.00. We collect a $25.00 deposit to secure the first
appointment. The deposit will be credited to the fees for the first session.
Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits,
whether individual or couple’s, that are appropriate in your case may be more or less than once per
week, depending upon your needs. Based upon a fee of $125.00 per visit, if you attend one
psychotherapy visit per week, your estimated charge would be $500.00 for four visits provided over the
course of one month; $1000.00 for eight visits over two months; or $1500.00 for 12 visits over three
months. If you attend therapy for a longer period, your total estimated charges will increase according
to the number of visits and length of treatment.
You have a right to initiate a dispute resolution process if the actual amount charged to you substantially
exceeds the estimated charges stated in this Good Faith Estimate (which means $400 or more beyond the
estimated charges).
You are encouraged to speak with your provider at any time about any questions you may have
regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

Date of this estimate: 01/01/2022