Good Faith Estimate Form
Your Right to a Good Faith Estimate
If you are uninsured or not using insurance for online psychotherapy services, you are entitled to receive a written Good Faith Estimate form detailing the cost of your therapy sessions. This estimate will outline the total expected charges for services provided, helping you make informed financial decisions about your care.
What You Can Expect
- You will receive a written Good Faith Estimate form before your first session or upon request.
- The estimate will include the cost per online psychotherapy session and any anticipated additional services.
- If your actual costs differ significantly from the estimate, you have the right to dispute the charges.
Estimated Therapy Costs
- Individual online psychotherapy sessions: $200 per session
- Unlimited DBT phone coaching: $125 per month
Dispute Resolution
If you receive a bill that is at least $400 more than what was listed on your Good Faith Estimate form, you have the right to dispute the bill. You can initiate a dispute through the U.S. Department of Health & Human Services (HHS).
For more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises.
Questions?
If you have any questions about your Good Faith Estimate or therapy costs, feel free to contact us. We are committed to transparency and ensuring you have clear information about your care.