GOOD FAITH ESTIMATE DISCLOSURE
(No Surprises Act – Effective January 1, 2022)
Provider: Teresa Zuvela, LMHC
Practice: Woodland Pathways Counseling
Service Delivery: Telehealth – Washington State
Your Right to a Good Faith Estimate
Under federal law, you have the right to receive a Good Faith Estimate of expected charges for mental health services if you are not using insurance or are choosing not to submit claims to insurance.
This document provides general information about fees and your rights under the No Surprises Act.
A personalized estimate will be provided once session frequency and type of services are determined.
Standard Self-Pay Fees for these services
- 45-minute individual psychotherapy
- 60– minute individual psychotherapy session
- 90-minute extended session
- Group therapy session
- Private intensives: quoted individually
Fees reflect specialized trauma-focused care, advanced certifications, and maintaining a smaller caseload for depth-oriented treatment. Disclosure of fees will be given at the time of the Free Consultation.
Important Information
- The total cost of therapy depends on session frequency and duration.
- You are not required to attend therapy for any specific length of time.
- You may discontinue services at any time.
If you are billed at least $400 more than your personalized Good Faith Estimate, you have the right to dispute the bill.
For dispute information:
www.cms.gov/nosurprises
1-800-985-3059
Client Acknowledgment
I acknowledge that I have received this Good Faith Estimate Disclosure.
Client Signature: ___________________________
Date: ___________________________