Good Faith Estimate

When starting therapy at  Trailside Therapy & Wellness LLC, we will provide a No Surprise Act Waiver,  Consent to Treat, and Good Faith Estimate for your consent:

I acknowledge that my provider at Trailside is considered an out-of-network provider by my insurance. Additionally, I acknowledge that my health insurance plan may cover mental health benefits for in-network providers. In the case where my insurance plan covers mental health benefits for in-network providers, I voluntarily waive that coverage, I voluntarily chose my out-of-network provider at Trailside Therapy, and voluntarily chose to pay the out-of-pocket/self-pay fee for any and all services rendered.

I agree that my psychotherapy rate will be $80-125/hr. unless otherwise specified in writing, and I understand that this fee is recurring as psychotherapy is recurring until either I or my provider terminate. A specific estimate of the total cost based on the duration of services for which I am seeking therapy may be requested by me from my rendering provider. This is our best-advised estimate of fees, but of course, estimates may change depending upon the course of therapy and the changing needs for treatment. I understand that I am responsible for paying the agreed-upon fee out-of-pocket for each appointment. I understand that it is within my rights to request and submit a superbill to my insurance company for reimbursement of services rendered; however, I understand there is no guarantee if or how much my insurance company will reimburse me. I understand that by requesting a superbill I am giving my provider permission to diagnose me and I understand that this diagnosis will become part of my permanent health record.

Last updated January 01, 2024

A Good Faith Estimate, Consent to Treat, and No Surprise Act Waiver will be signed prior to intake.