No Surprises Act

Dear Patients,
As of 2022, California passed the No Surprises Act (H.R. 133), which requires all healthcare providers, including psychotherapists, to offer a “Good Faith Estimate” to patients or clients who are either not using health insurance or do not have health
insurance, detailing the expected charges for mental and medical health services. While it is not possible for a psychotherapist to predict in advance how many psychotherapy sessions may be necessary or appropriate for an individual, this form provides an estimate of the cost of services provided. The total cost of services will depend on the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services provided.
Under this law, you have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy. You can request a Good Faith Estimate from your healthcare provider, or any other provider you choose, before scheduling a service.
There may be additional items or services we may recommend as part of your care that must be scheduled or requested separately, and are not reflected in this Good Faith Estimate. Please note that 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. If you receive a bill that exceeds your Good Faith Estimate by $400 or more, you have the right to dispute the bill. Be sure to keep a copy or photo of your Good Faith Estimate for reference. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit
https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059. Initiating the patient-provider dispute resolution process will not affect the quality of the services provided to you.