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How to write a good faith estimate (with a template)

Looking for a good faith estimate template for therapists? Here’s what to know about writing them, as well as an example.

Ryan DeCook
Ryan DeCook, LCSWTherapist

Transparency and trust are crucial to a healthy relationship between you and your clients. One way to foster this is by providing a good faith estimate (GFE). This document can help build client trust and show your commitment to being a trustworthy clinician. Providing this estimate also keeps your practice in compliance with federal law, so it is especially important to have a quality estimate template in place.

What is a good faith estimate?

A good faith estimate is a written document provided to self-pay clients who are uninsured or are choosing not to use their insurance for therapy. The document provides the client a list of the costs for offered services in advance so the client can see their estimated costs before starting therapy. This typically includes assessment fees, session fees, administrative tasks, and any other foreseeable costs associated with services. While the estimate may not cover every possible expense, it should provide as detailed and comprehensive of an estimate as possible. The estimate is designed to protect clients from hidden expenses and is a requirement of the federal No Surprises Act.

Adhering to the No Surprises Act

In January 2022, a federal law named the No Surprises Act went into effect. The law aims to bring transparency and protection to healthcare, and to ensure patients are not burdened by unexpected costs from situations beyond their control. The specific purpose behind the law was to protect people from surprise bills and hidden expenses after receiving care, particularly in healthcare emergencies. Patients often received unexpected bills for emergency care, especially when using out-of-network providers. 

As the bill was developed, it expanded to incorporate all healthcare providers (including therapists) after lawmakers realized that unexpected costs were a problem in all areas of healthcare, not just emergency situations. Besides cost limits, a core part of that law is the requirement of good faith estimates. These written notices are required to be provided in advance of rendered services. As a therapist, this means you must provide this estimate to cash-pay clients days in advance of your first therapy appointment.

Another key component of the No Surprises Act is dispute resolution. This takes the pressure off of a client to resolve any payment discrepancies with a provider by involving a third party. If a self-pay client receives a bill that exceeds the GFE by $400 or more, the client can start a dispute process through an application with the U.S. Department of Health and Human Services. This process is called the patient-provider dispute resolution. Clients must initiate the process within 120 days of receiving the excessive bill and must provide documentation of the bill and the original GFE. An independent arbitrator will then review the submission and make a determination on the amount that the client is responsible for. Their determination is final and therapists may face penalties for noncompliance with the Act. Your GFE must include a note about this right of the client to the dispute resolution process.


Your GFE must be provided to clients within a specific time window, including the following:

  • If a scheduled service is at least 10 days in advance, then the GFE must be provided within 3 business days of the date of the appointment scheduling. 
  • If an appointment is scheduled 3 to 9 days in advance, the GFE must be provided no later than 1 business day after the date of scheduling. 
  • If an appointment is scheduled fewer than 3 business days in advance, then no GFE is legally required, but many therapists still choose to offer this as best practice. 
  • If a client requests a copy of the GFE at any point, it must be provided within 3 business days from the time of request. 
  • If there are any changes to costs or the GFE, a copy must be provided at least 1 business day before the scheduled service. 

How to write a good faith estimate

Compliance with the No Surprises Act as a therapist is relatively straightforward. Creating a quality good faith estimate that you provide to all cash-pay clients will ensure the majority of your compliance. A reusable template will minimize both your workload and risk. A platform like Headway makes it easy to save and reuse templates like this and share it electronically with clients. 

What to include in a good faith estimate

  • Client’s name and date of birth
  • A description of the primary services being offered to the client (e.g. individual therapy) and the scheduled date of that service if applicable 
  • A list of diagnostic and service codes, such as CPT codes, and the expected fees for each listed item
  • An itemized list of any other goods or services that could reasonably be expected to arise during the period of care along with the cost of each item
  • Your provider information including name, National Provider Identifier (NPI) number, tax ID number, and the location(s) where services will be provided
  • A total cost estimate for all services and items. While it can be difficult to estimate this for clients up front, it can be effective to provide a range of estimates. You can list a range of possible session frequencies in a year (e.g. weekly, bi-weekly, monthly) and then multiply those numbers by the cost per session to give a range of total cost
  • The estimated costs are only valid for 12 months from the date of the GFE.

Required disclaimers

  • The client has the right to initiate the dispute resolution process if their actual bill is $400 (or more) over the GFE.
  • The GFE is not a contract and does not obligate the client to utilize the listed services.
  • The GFE is based on information known at the time. It is only an estimate and actual charges may differ.
  • Additional services that are not included in the GFE may be recommended by the therapist. Those services must be scheduled separately.
  • While it is not required, it is a good idea to inform the client that fees can change at any time and advance written notice (e.g. 30 days) would be provided if this occurs. This lays the ethical groundwork to be able to raise your therapist rates if needed.

Good faith estimate template

Provider information:

Practice name: [Your practice name or therapist name]

Provider name & credentials: [Therapist name, degree/license]

NPI number: [NPI number]

Tax ID dumber: [TIN]

Contact: [Phone number] | [Email address]

Office address(es): [Primary office address]

[Additional locations, if applicable]


Client information:

Client name:

Date of birth: 

Date of Good Faith Estimate:

Estimate valid through: 12 months from the above date


Service description: Initial evaluation 

Service code: 90791

Cost per service: $[amount] (e.g. $150)


Service description: Individual therapy (60 min)

Service code: 90837

Cost per service: $[amount]


Service description: Individual therapy (45 min)

Service code: 90834

Cost per service: $[amount]


Service description: Couples/family therapy

Service code: 90847

Cost per service: $[amount]


Estimated total cost for one year (Individual therapy):

Example based on weekly sessions: (e.g., $150 x 52 = $7,800)

Example based on bi-weekly sessions: (e.g., $150 x 26 = $3,900)

Example based on monthly sessions (e.g., $150 x 12 = $1,800)

Actual number of sessions may vary depending on treatment needs.


Diagnosis code (if known): ___________________

Client declines to receive a formal diagnosis at this time. (if applicable)


Additional fees (if applicable)

  • Letter/report writing: $[amount]/hr
  • Records requests/admin: $[amount]
  • Returned check fee: $[amount]
  • Court/legal fees: $[amount]/hr (see Practice Policies for details)
  • Other: __________________________

Please refer to our Practice Policies for a complete list of fees and services. Fees are subject to change with 30 days’ written notice.


Disclaimer & required notices

  • This Good Faith Estimate (GFE) shows the costs of services that are reasonably expected for your mental healthcare needs based on information known at the time of estimate. The actual charges may differ if your needs or treatment plan change.
  • The GFE does not include unknown or unexpected costs that may arise during treatment. You may be charged more if complications or special circumstances occur.
  • If you receive a bill that is at least $400 more than this GFE, you have the right to dispute the bill.
  • You may contact [Provider name or practice] at the contact information above to discuss the bill, request an updated GFE, negotiate charges, or inquire about financial assistance.
  • You may also initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days of receiving the bill. There is a $25 fee to use this process. If the agency agrees with you, you will pay the GFE amount; if not, you may be responsible for the higher charge.
  • For more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.


This GFE is not a contract and does not obligate you to receive the services listed.


Keep a copy of this Good Faith Estimate in a safe place. You may need it if you are billed more than $400 above this estimate.

I acknowledge receipt and understanding of this Good Faith Estimate.


Printed name:

Relationship to client (if applicable):

Signature: 

Date:

How Headway can help your billing process

When it comes to administration and insurance billing, Headway handles all of the busy work for your therapy practice. Our simplified provider platform saves you time on your entire workflow by allowing you to easily handle scheduling, documentation, and insurance claims from one place. With built-in template management and digital delivery tools, Headway helps you stay compliant with federal laws like the No Surprises Act.

Headway streamlines your caseload with access to a suite of free EHR features, built-in documentation, and assessments. This includes tools to store and share forms like the good faith estimate with clients. This allows you to focus less on administration and more on your clients. More than 50,000 providers nationwide already use these features (and more) to save time, stress less, and build their best practice.

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