Below is a general outline of the “Good Faith Estimate” form. The form a client will receive during the intake process will contain specific information regarding types of sessions, costs per session type, and client information.
Effective January 01, 2022, based on the “No Surprises Act”, you have the right to receive a “Good Faith Estimate” (GFE) explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are opting to not use their insurance an estimate of the expected charges for medical services, including psychotherapy services. For questions or more information about your right to a Good Faith Estimate when visiting a health care provider, you may visit: www.cms.gov/nosurprises.
Provider Name: Leslie E. Aguilar, LMFT #110851
Provider Address: 12725 Ventura Blvd., Suite I, Studio City, CA 91604
Provider Phone Number: (424) 501-4590
Provider NPI: 1508214594
Client Name:
Client Address:
Client Phone Number:
Client Email:
Client Diagnosis/es (if applicable):
Psychotherapy Services Requested:
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 fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $______. Most clients
will attend one psychotherapy visit per week, yet the frequency of psychotherapy visits that are
appropriate in your case may be more or less than once per week, depending upon your therapeutic needs.
Based upon a fee of $______ per visit, if you attend one psychotherapy visit per week, your
estimated charge would be $______ for four visits provided over the course of one month;
$______ for eight visits over two months; $______ for 12 visits over three months; etc. If you attend
therapy for a longer period, your total estimated charges will increase according to the number of
visits and length of treatment.
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).
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.
Date of this GFE:
Client Signature: