Good Faith Estimate
RIGHT TO RECEIVE A GOOD FAITH ESTIMATE NOTICE
The federal government now requires all healthcare providers to provide a Good Faith Estimate for the cost of professional services. You have the right to receive a “Good Faith Estimate” explaining what your mental health care will cost. 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 or couple therapy sessions you have scheduled. 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 specified here. YOU WILL INCUR A FULL FEE CHARGE FOR ANY SESSION NOT CANCELLED PRIOR TO 48 BUSINESS HOURS BEFORE YOUR SCHEDULED SESSION.
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 total 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.
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. 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 in this Good Faith Estimate.
Name: Mari K. Hayes
Depending on your therapy goals, you may need between 1 and 200 (or more) psychotherapy sessions of 45 minutes each this year. Currently, my fees are $180 for individual therapy and/or supervision of cases. For couple therapy, my fee is $200 per session. Any changes from this will be discussed between you and me. THERE WILL BE A FULL FEE CHARGE FOR MISSED SESSIONS NOT CANCELLED PRIOR TO 48 BUSINESS HOURS IN ADVANCE OF YOUR SCHEDULED SESSION.