Insurance & Superbill Information

Circle City Alliance Therapy & Consulting is an out-of-network provider, which means we do not bill insurance directly (fees listed below). However, we can provide a superbill (a detailed invoice) for you to submit to your insurance company for possible reimbursement, depending on your plan. Before starting therapy, you may want to check your call your insurance provider and ask:

  • Do I have out-of-network mental health benefits?

  • What is my deductible, and has any of it been met?

  • What percentage of therapy sessions do you reimburse?

  • Is there a limit on the number of sessions covered?

Choosing an out-of-network therapist gives you more privacy and flexibility in your treatment — together, we decide what your care looks like, not your insurance company.Benefits Calculator

Not sure if you have out-of-network benefits?

Use the calculator below and get an instant answer to your benefits questions. Get information on your benefits, remaining deductible, and reimbursement rates.

Billing & Fees

  • Individual Therapy (50 minutes): $150

  • Brainspotting Intensives (100 minutes): $300
    Extended sessions can be scheduled in advance for clients seeking deeper work or intensive support. These longer sessions are especially helpful for Brainspotting and trauma-focused work.

Cancellation & No-Show Policy

We hold your session time just for you. To honor both of our time and commitment:

  • Same-day cancellations will be charged a $50 fee

  • No-shows (missed sessions without prior notice) will be charged the full session rate of $150

If you need to reschedule or cancel, please provide at least 24 hours' notice to avoid these fees.

Good Faith Estimate

Circle City Alliance Therapy & Consulting
Client Financial Disclosure & Good Faith Estimate
Therapist(s):Ethany Michaud, LCSW

Provider and Client Information

This Good Faith Estimate is provided by Ethany Michaud, LCSW. Circle City Alliance Therapy & Consulting uses NPI Number 1952917312 and TIN/EIN 99-4100285.

Services and Fees

The standard fee for a 50-minute Individual Therapy session is $150.00, and the fee for a 90-minute Group Therapy session is $50.00. Should you request an intensive individual therapy session, the price will increase accordingly: a 100-minute session would cost $300.00. Each additional 50 minutes beyond the standard session will cost another $150.00.

Your therapist will collaborate with you throughout your treatment to determine the number of sessions and/or services you may need to receive the greatest benefit based on your clinical concerns. For example, if you choose to attend weekly sessions based on your treatment needs, your yearly cost could be $7,800. Bi-weekly therapy could cost $3,900.

Good Faith Estimate Statement

Under the federal No Surprises Act (and applicable Indiana law), you have the right to receive a good faith estimate of the expected charges for your non-emergency services if you are self-pay or are not using insurance. This estimate reflects our best approximation of your cost. If you choose to use insurance later, this estimate may no longer apply. This estimate is valid for 90 days past termination of services from the date signed below.

Payment & Cancellation Terms

Payment is due per session at the time of service, unless otherwise agreed upon. Our cancellation policy is strictly enforced to ensure continuity of care:

  • If you cancel or reschedule an appointment with less than 24 hours' notice, a missed session fee of $50.00 will be charged.

  • For all no-call, no-show appointments (where no notice is given before the session time), the fee is the full session rate of $150.00.

Notice of Rights and Protections

You are not required to obtain services from this practice. You have the right to ask us or any other provider for a written estimate of what you will be charged.

  • Federal Dispute Right: If a bill is at least $400 more than this good faith estimate (the federal threshold), you have the right to dispute the bill.

  • Indiana Right: Indiana law also grants you the right to request a written cost estimate within five business days of a request for a scheduled non-emergency service.

Dispute Resolution Contact Information (Required by Federal Law):

If you are billed for more than the estimate, you have the right to initiate the patient-provider dispute resolution process. For questions or more information about your right to a Good Faith Estimate or the dispute process, please visit www.cms.gov/nosurprises or call 1-800-985-3059.

Acknowledgement

I have read and understand this Good Faith Estimate & Financial Disclosure and the information provided above regarding my rights under the No Surprises Act and Indiana cost-estimate laws.

Acknowledgement (Client) I have read and understand this Good Faith Estimate & Financial Disclosure and the information provided above regarding my rights under the No Surprises Act and Indiana cost‑estimate laws.

Optional Additional Waiver (if applicable)I understand that I am choosing to receive services from an out‐of‐network provider/facility. By signing below I agree to give up certain protections under the No Surprises Act. I understand that by doing this I may be responsible for higher costs and that these costs may not count toward my health plan deductible or out‑of‑pocket limit.