Good Faith Estimate:
This notice explains your right to receive a Good Faith Estimate of expected charges for psychotherapy services if you are not using insurance and are paying out of pocket.
What is a Good Faith Estimate?
A Good Faith Estimate is an estimate of the cost of mental health services you may receive. Because therapy is individualized, the total number of sessions—and therefore the total cost—cannot be known in advance. Your actual charges will depend on how many sessions you attend and the type of services provided.
This estimate:
Is not a contract
Does not require you to receive services
Does not guarantee a specific number of sessions
May change if your treatment needs change
Current Self‑Pay Fees
Psychotherapy session (in person or telehealth): $______ per assessment and $______ per session
Most clients attend approximately one session per week, though frequency may be more or less depending on your needs. You are encouraged to discuss treatment frequency, duration, and costs with your therapist at any time.
Your Rights
If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to dispute the bill.
You may:
Contact your provider to request a correction, negotiation, or financial assistance, or
Initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS)
Disputes must be initiated within 120 days of the original bill
There is a $25 filing fee
More information: www.cms.gov/nosurprises
HHS Help Line: (800) 368‑1019
Using the dispute process will not affect the quality of your care.
Acknowledgement
By signing below, you acknowledge that:
You have received and reviewed this Good Faith Estimate notice
You understand this applies to self‑pay services
You understand that total costs depend on the number of sessions you attend