What is this page for? This information is for clients who are not using insurance for therapy. It explains your right to receive a clear estimate of the cost of services before you begin — so there are no unexpected charges.

This is part of a federal law called the No Surprises Act, and we’re required to provide this to all self-pay clients.

 

As part of the No Surprises Act, which took effect on January 1, 2022, all healthcare providers are required to inform clients of their rights to avoid unexpected or “surprise” medical bills.

 

Because you’re either uninsured or have chosen not to use insurance for therapy, you’re entitled to a Good Faith Estimate that outlines the expected cost of services. You’ll find that estimate attached.

 

Please keep in mind:

It’s not always possible to predict how long therapy will last. You’ll work with your therapist to decide how many sessions feel right for your needs. The attached document includes a list of services and fees to help you plan. 

If you have any questions about the estimate or your rights under this law, don’t hesitate to bring them up with your therapist. We’re here to help. 

 

GOOD FAITH ESTIMATE

Client Name:

Date of Birth:

Address:

Phone #:

Email:

Diagnosis (if known/applicable):

Responsible Party (if not the client):

Client’s Contact Preference    [ ] By mail   [ ] By email    [ ] By phone

Date of Scheduled Service: _________/________/_________

[ ] Check this box if this service or item is not yet scheduled

IMPORTANT: A formal diagnosis may occur after a diagnostic assessment has been completed. Your therapist will discuss, as relevant, diagnosis(es) as applicable to treatment.

It is within your rights to decline a formal diagnosis.

 

Good Faith Estimate for Therapy Services

Effective January 1, 2022 – In compliance with the No Surprises Act

 

Under federal law, you have the right to receive a Good Faith Estimate (GFE) explaining how much your mental health care will cost- before you receive services.

You’re entitled to this estimate if:

You don’t have insurance, orYou’re choosing not to use your insurance for servicesThis estimate shows the expected costs for services based on what’s known today. It is not a bill , not a treatment plan, and not a guarantee of total cost. Actual costs may change depending on your needs or changes in your care.

Therapy Service Fees

 

Standard 50-minute therapy session (in person or telehealth): $150Most clients attend therapy once per week, but frequency may vary depending on your needs. 

You can calculate your estimated cost by multiplying the $150 session fee by the number of sessions. Below are common estimates:

 

Duration of Treatment

1 Session/Week

2 Sessions/Week

1 Week

$150

$300

3 Months (13 weeks)

$1,950

$3,900

6 Months (26 weeks)

$3,900

$7,800

 

 

 

9 Months (39 weeks)

$5,850

$11,700

12 Months (52 weeks)

$7,800

$15,600

 

You may also want to plan for missed sessions due to illness, holidays, or emergencies.

Other Possible Fees

 

Additional Service

Fee

Late Cancellation / No-Show

$75 per missed session

Record Request

$25 per request

Letters or Report Writing

$50 per 15 minutes

Court Appearance / Prep Time

$250 per hour

 

These are optional services and will only apply if needed or requested.

 

What Affects Your Total Cost

Each person’s therapy journey is different. Your total cost depends on:

How long you remain in therapyHow often you attend sessionsWhat challenges you’re working throughYour schedule, resources, and preferencesYou and your therapist will regularly check in about your progress and treatment plan. If your needs change significantly, we’ll issue a new Good Faith Estimate upon request.

 

Important Legal Disclaimer

This Good Faith Estimate is based on the best information available at the time it was given.

You may be charged more if complications or special circumstances arise.You have the right to dispute a bill that is $400 or more above your Good Faith Estimate.If this happens, you can contact your provider to:

Discuss the chargesAsk to update the bill to reflect the estimateInquire about payment options or financial support 

You can also start a formal dispute process through the U.S. Department of Health and Human Services.

To file a dispute:

Visit: www.cms.gov/nosurprises/consumersOr call: 1-800-985-3059 

There is a $25 fee to start this process. If the dispute is resolved in your favor, you will pay the amount on this estimate (minus the $25 fee). If not, you may be required to pay the higher amount.

 

Final Note

Keep this estimate for your records. If you have questions about your bill or want to request a new estimate at any time, please contact your provider directly.

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Client/Legal Guardian Signature: ____________________________ Date: ________________

                                               

Printed Name: ___________________________________________Date: _________________  

 

Client/Legal Guardian Signature: ____________________________ Date: ________________

                                               

Printed Name: ___________________________________________Date: _________________