Cassandra Gilbert, LPCC | cassandragilbert.com

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Your Right to a Good Faith Estimate

Under the No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate of expected costs for healthcare services, including mental health services, before your first appointment or upon request.

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What This Means for You

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As a self-pay or uninsured client, you are entitled to a written Good Faith Estimate of the anticipated cost of services before beginning treatment. This estimate will be provided to you prior to your first session or upon request at any time during treatment.

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Good Faith Estimate — Expected Costs

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• Provider: Cassandra Gilbert, LPCC

• Service: Individual psychotherapy — telehealth

• Session length: 50 minutes

• Session rate: $150 per session

• Sliding scale: Available upon request

• Billing codes typically used: 90837 (psychotherapy, 60 min) or 90834 (psychotherapy, 45 min)

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The total cost of treatment depends on the number of sessions attended, which varies based on individual needs and therapeutic goals. The length and frequency of treatment will be discussed collaboratively at the start of services and reassessed throughout.

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Important Disclaimers

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• This Good Faith Estimate is not a contract and does not obligate you to receive services.

• Actual charges may differ from this estimate based on your individual treatment needs.

• If your final bill is $400 or more than this Good Faith Estimate, you have the right to dispute the bill.

• This estimate does not include costs from other providers who may be involved in your care.

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Questions or Disputes

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If you have questions about this notice or your Good Faith Estimate, please contact:

Cassandra Gilbert, LPCC hello@CassandraGilbert.com cassandragilbert.com

For information about your rights under the No Surprises Act or to initiate a dispute, visit: cms.gov/nosurprises