Good Faith
Estimate

Effective January 1, 2022, the No Surprises Act requires providers to give a Good Faith Estimate (GFE) of expected charges to individuals who are uninsured or choosing not to use insurance.

Under federal law, you are entitled to receive an estimate of expected costs prior to services or upon request.

Please Note:
This requirement does not currently apply to clients using insurance (including out-of-network reimbursement). However, this estimate is provided so you understand potential costs if your insurance changes or you become a self-pay client.

Good Faith Estimate Overview

This estimate outlines expected costs based on information available at the time it is created. It does not include unforeseen or additional costs that may arise during treatment.

If you are billed more than your Good Faith Estimate:

• You have the right to dispute the bill
• You may request a correction, negotiate charges, or ask about financial assistance
• You may also begin a dispute process with the U.S. Department of Health and Human Services (HHS) within 120 days of the original bill (fee: $25)

Psychotherapy Services Disclaimer

Because therapy is individualized, it is not possible to predict the exact number of sessions needed. Total costs will depend on your unique needs, session frequency, and type of services provided.

This estimate:

• Is not a treatment recommendation or guarantee of services
• Is not a contract or obligation to receive care
• Applies only to the services listed
• Allows you to stop treatment at any time

You are encouraged to discuss any questions or concerns with your provider.