Good Faith Estimate Information
Information About Good Faith Estimates
All my counseling clients have a right to receive a “Good Faith Estimate” per federal law as of January 1, 2022. A Good Faith Estimate enumerates the expenses you can reasonably expect to pay for your mental health care services provided by me and my counseling practice. 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 upon the initiation of psychotherapy, 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. The estimate is created based upon the information known at the time the estimate is first created. It does not include unknown or unexpected costs that may arise during treatment. It is possible you may incur more charges than the estimate enumerates if complications or special circumstances arise.
If this happens, the federal law provides you a right to dispute your bill. If you are billed for $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact me directly to if you are billed charges that exceed the Good Faith Estimate. You can request for me to update your bill to match the Good Faith Estimate, request to negotiate the bill, or you may request information about financial assistance availability. You also have the right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days from the date on the original bill. There is a $25 fee to use the dispute process. If the dispute-reviewing agency agrees with you, you will be responsible for the amount provided on your Good Faith Estimate. If the agency disagrees with your dispute and agrees with the fees charged by me that exceed the Good Faith Estimate, you will have to pay the higher amount charged. To learn more visit www.cms.gov/nosurprises or call HHS at (800) 368-1019.
Your estimate is not a contract. You are not obligated to receive services from me. My office can provide you with alternative referrals at your request at any time. Below is a schedule of standard fees for my clinical services for clients who are selfpay. Reduced fees are available based on financial criteria and circumstances per a reduced fee application and committee review process.
The following are fees as of 2/15/2023.
Initial Intake Evaluation/Session – $375
Functional Mental Health Intake – $450
Individual Therapy / Somatic Session / Coaching Session (45-50 minutes)– $350
Record Requests Admin Feel - $35
GFE/Bill Dispute Fee – $25
Court involved work not billable for reimbursement to your insurance – $350 per hour