GOOD FAITH ESTIMATE

[Note: This form is to provide a current or prospective client with a “Good Faith Estimate” (GFE) of expected charges for services provided pursuant to the No Surprises Act.]

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. 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, 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. This estimate 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.  

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy 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 consultation 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.

The first session is an Intake Diagnostic Assessment, including history, present context, and a compilation of the client’s story and mental status. The first session fee is $100.00. The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $100.00.  Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $100.00 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $400.00 for four visits provided over the course of one month; $800 for eight visits over two months; or $1200  for 12 visits over three months; and $5200 for 52 visits (1x/week for 12 mos). If you attend therapy more/less frequently, your total estimated charges will increase/decrease according to the number of visits and length of treatment.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

You have a right to initiate a dispute resolution process, if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

Every intention to be forthright with fee estimates has been scrupulously considered and applied to this Good Faith Estimate. Client agrees to hold Julia Vering and Expressive Arts Therapy KC LLC Harmless from liability beyond what could be known at the time of this estimate.

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.

Date of this Estimate:  ?/??/22

Client Name:                                   

Guardian/Parent Name (If applicable):