Good Faith Estimate for Psychotherapy Services

Notice of Your Rights Under the No Surprises Act

At Counseling4Change, LLC, I believe in transparency and helping clients understand the cost of mental health care before beginning treatment.

Under the federal No Surprises Act, individuals who do not have health insurance or who choose not to use their insurance to pay for services have the right to receive a Good Faith Estimate of the expected costs of psychotherapy services.

What Is a Good Faith Estimate?

A Good Faith Estimate (GFE) is a written estimate of the expected charges for health care services you may receive from this practice. It is intended to help you understand and plan for the cost of psychotherapy.

You may request a Good Faith Estimate before scheduling an appointment or at any time during the scheduling process. If you are uninsured or choose to self-pay, you are generally entitled to receive an estimate when you schedule services at least three business days in advance or when you request one.

What Does This Mean for Psychotherapy?

The cost of psychotherapy depends on the services you receive and the frequency of your appointments. Your Good Faith Estimate may include anticipated charges for:

  • Initial psychotherapy intake or evaluation sessions.

  • Individual psychotherapy sessions.

  • Family or couples psychotherapy sessions, if offered by this practice.

  • Other services that are reasonably expected to be provided as part of your anticipated course of care.

Your estimate will reflect the services and fees reasonably anticipated at the time it is prepared. If your treatment needs or appointment frequency change, your anticipated costs may change as well.

How Much Does Psychotherapy Cost?

My current self-pay fees are:

  • Initial intake and individual psychotherapy sessions: $130 per 45-minute session

These fees are provided for general informational purposes. Your individualized Good Faith Estimate will identify the expected charges for the services reasonably anticipated for you.

When Will I Receive My Estimate?

You may request your Good Faith Estimate before scheduling services. Federal rules generally require that it be provided within three business days of your request.

For scheduled services, the required timeframe generally depends on how far in advance the appointment is scheduled:

  • 3–9 business days before the appointment: The estimate is generally due within one business day after scheduling.

  • 10 or more business days before the appointment: The estimate is generally due within three business days after scheduling.

Your estimate may be provided electronically or on paper, according to your preference.

What If My Bill Is Higher Than My Estimate?

You have the right to initiate the federal Patient-Provider Dispute Resolution process if the amount billed by this practice is at least $400 more than the expected charges listed in your Good Faith Estimate from this practice, provided the applicable eligibility requirements are met.

You generally must initiate the dispute within 120 calendar days of receiving the initial bill.

For information about this process, visit the Centers for Medicare & Medicaid Services (CMS) website:

Learn how to dispute a medical bill

You may also contact the No Surprises Help Desk at 1-800-985-3059.

How Do I Request a Good Faith Estimate?

To request an estimate or ask questions about psychotherapy fees, please contact:

Practice: Counseling4Change, LLC
Provider: Arthur H. Belmont, LMFT
Phone: 888-787-1767
Email: Arthur.Belmont3@pm.me

I welcome questions about fees and anticipated treatment costs so that you can make informed decisions about your care.

Please Keep Your Estimate

A Good Faith Estimate is not a bill or a guarantee of the final cost of treatment. Actual charges may differ from the estimate if the services provided or your treatment needs change.

Please keep a copy of your estimate and compare it with any bill you receive.

For additional information about your rights under the No Surprises Act, visit:

CMS: Know Your Rights When Paying for Health Care Without Insurance

This notice is intended to inform uninsured and self-pay clients of their rights under applicable federal law.