Good Faith Estimate (GFE) for Psychotherapy Services
For Self-Pay (Uninsured) Clients
Effective Date: January 1, 2022
📌 Purpose of This Estimate
Under federal law (the No Surprises Act), you are entitled to receive a Good Faith Estimate of expected charges for psychotherapy services provided to you.
This estimate helps you understand your potential costs before you receive care. Please note:
- This is not a contract and does not obligate you to obtain services from this provider.
- This estimate is based on information known at the time of issue and does not include unknown or unexpected costs that may arise.
- You can discontinue therapy at any time.
💬 Understanding Your Treatment and Costs
The number of sessions and total cost will depend on your individual needs, treatment goals, and frequency of sessions agreed upon with your therapist.
Common Services and Fees
| Service | CPT Code | Fee |
| Psychiatric Diagnostic Evaluation (Intake) | 90791 | $250.00 |
| Psychotherapy, 30 minutes (16–37 min) | 90832 | $175.00 |
| Psychotherapy, 45 minutes (38–52 min) | 90834 | $200.00 |
| Psychotherapy, 60 minutes (53–60 min) | 90837 | $225.00 |
| Family Therapy without patient present | 90846 | $250.00 |
| Family Therapy with patient present | 90847 | $250.00 |
| Group Psychotherapy (non-family) | 90853 | $50.00 |
| Late Cancellation (< 24 hours’ notice) | — | $150.00 |
| Missed Appointment (no-show, no contact) | — | $150.00 |
📅 Example Cost Estimates Based on Session Frequency
Most clients begin with one initial intake session, followed by one weekly psychotherapy session. These are only estimates and may vary based on your treatment plan.
Based on $200/session (45-minute sessions):
- Monthly (4 sessions): $800
- 2 Months (8 sessions): $1,600
- 3 Months (12 sessions): $2,400
- 1 Year (52 sessions): $10,400
Based on $225/session (60-minute sessions):
- Monthly (4 sessions): $900
- 2 Months (8 sessions): $1,800
- 3 Months (12 sessions): $2,700
- 1 Year (52 sessions): $11,700
You may attend more, or fewer sessions based on your needs and preferences. These costs will adjust accordingly.
💳 Payment Information
- Payment is due at the time of service.
- Accepted forms: [Cash, Credit Card, HSA Card, Flex Spending, Check ]
- A $25 fee will be charged for any returned checks due to insufficient funds.
- All clients are required to have a valid credit card on file on file for payment processing.
📢 Dispute Information & Your Rights
If you receive a bill that is at least $400 more than this Good Faith Estimate, you have the right to dispute the charges.
You may:
- Contact your provider to discuss the bill
- Request a revised bill to match the estimate
- Ask about payment plans or financial assistance
Or initiate a dispute through the U.S. Department of Health and Human Services (HHS):
- Website: www.cms.gov/nosurprises/consumers
- Phone: 1-800-985-3059
- Dispute Filing Window: Within 120 calendar days of the date on your bill
- Dispute Fee: $25
If the review agrees with you, you will pay the amount on the estimate. If it favors the provider, you may be required to pay the higher charge.
✅ Acknowledgment
You are encouraged to speak with your provider about any part of this estimate or your treatment plan at any time.
Please keep a copy of this estimate for your records. You may need it if there is a billing discrepancy.