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.

For questions or more information about your right to Good Faith Estimate or the dispute 

process, visit https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059. The

initiation of the patient-provider dispute resolution process will not adversely affect the quality of

the services furnished to you.