Good Faith Estimate

FOR HEALTHCARE ITEMS & SERVICES

You are entitled to receive a Good Faith Estimate (GFE) of what the charges could be for clinical mental health counseling (also called psychotherapy) services provided to you. While it is not possible for a psychotherapist to know, in advance, how many counseling sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of counseling sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. 

This GFE is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. It does not include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate. Please contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.

This GFE is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of counseling visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in collaboration with your therapist You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.