Good Faith Estimate | No Surprise Act of 2021

Applies to clients who are self-pay.

A new federal law passed called the “Good Faith Estimate” (GFE) and it’s designed to protect against surprise medical bills. We’re legally mandated to post the notice on our website. Under the law, medical providers must provide a GFE of possible charges that may be billed to individuals who are uninsured or who are self-pay. 

The GFE must be provided both orally and in writing, upon request, or at the time of scheduling health care items and services. Keep in mind, a GFE is an estimation of the expected charges related to proper treatment.

Your right: To understand a diagnosis and know anticipated charges.


Common billing codes and full rates for counseling services at our clinic include, but are not limited to:

(Rates Effective May 1, 2022)

CPT billing Code 90791: $250

CPT billing Code 90832: $95.00

CPT billing Code 90834: $150.00

CPT billing Code 90834: $190.00


In addition, these are common diagnostic codes used by the clinic:

  • Separation Anxiety Disorder (F93.0)
  • Other Phobias (F40.298)
  • Social Anxiety Disorder (F40.10/F40.11)
  • Panic Disorder (F41.0)
  • Generalized Anxiety Disorder (F41.1)
  • Obsessive-Compulsive Disorder (F42.2)
  • Hair Pulling Disorder (F63.3)
  • Attention Deficit Hyperactivity Disorder (F90.8x)
  • Post Traumatic Stress Disorder (F43.1)
  • Adjustment Disorder with Anxiety (F43.22)
  • Adjustment Disorder with Depressed Mood (F43.21)
  • Mixed Anxiety/Depression (F43.23)

Estimate Examples:

1) If you complete 1 assessment and attended 6 sessions in 3 months period using the 90834 code, your estimated total bill would be $1,390.00.

2) Another example – You attended 6 sessions in 3 months at the 90834 code, without needing an assessment your estimated total bill would be $900.00.

Does that make sense? Let us know if you have any questions at any time. We’re here to help.

Length and frequency of treatment:

Our treatment plans are 3 months. For various reasons, the treatment plan may be extended to 6 months.

Once the contracted rate, diagnosis, and frequency of sessions are determined, your GFE will be discussed with you.

Upon request, a GFE will be provided in writing. It is our policy that treatment plans are reviewed every 3 months.

Good Faith Estimate Disclaimers

This GFE shows a general estimated cost of items and services that are reasonably expected for your treatment plan, based on information known at the time the estimate was created. 

You could be charged more if you attend sessions more frequently or extend your treatment plan. 

If you believe you’ve been over-charged, federal law allows you to appeal and dispute the bill. If you are billed more than your individualized GFE estimate, you have the right to dispute the bill.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the original bill. 

To learn more and get a form to start the process, call 1-800-985-3059 or visit For questions or more information about your rights to a Good Faith Estimate or the dispute process, visit