Counseling Good Faith Estimate Form for Mental Health Professionals (PDF & Word Doc)

Providing clients with a clear estimate of expected treatment costs is an important part of transparent financial communication in mental health practice. A Good Faith Estimate helps document the anticipated services, fees, and potential charges a client may receive before beginning care. For self-pay clients and individuals who choose not to use insurance, a structured estimate form provides a clear record of expected expenses while supporting compliance with applicable requirements under the No Surprises Act.

TherapyByPro’s Counseling Good Faith Estimate Form is a comprehensive documentation template designed for mental health professionals providing outpatient counseling and psychotherapy services. Available as both an editable Word document and fillable PDF, the form documents provider information, client details, diagnosis information, expected services, CPT codes, estimated charges, potential additional fees, payment information, dispute rights, and client acknowledgment. The template supports documentation of expected mental health service costs before treatment begins.

The form begins by documenting important estimate details, including the Good Faith Estimate number, issue date, validity period, update dates, provider information, and client information. A dedicated section records insurance status, diagnosis information when available, and the clinical information used to determine the expected services and estimated charges.

Additional sections document the estimated service period, anticipated number of sessions, CPT codes, service descriptions, estimated quantities, and projected charges. The form also identifies services not included in the estimate, potential additional charges, payment methods, financial arrangements, client dispute rights under the No Surprises Act, and required signatures confirming receipt and understanding of the estimate.

What Is Included in This Counseling Good Faith Estimate Form

This comprehensive Good Faith Estimate template includes documentation commonly used when providing clients with expected cost information for mental health services:

• Estimate and Provider Information: Documents the Good Faith Estimate number, issue date, validity period, provider details, clinician credentials, NPI information, tax ID, contact information, and practice address.
• Client Information: Records client identifying information, contact details, and insurance status related to the estimated services.
• Diagnosis Information: Provides space to document diagnosis information or indicate that diagnosis is pending evaluation and may be updated when additional information becomes available.
• Expected Services and Charges: Documents estimated treatment dates, expected number of sessions, CPT codes, service descriptions, estimated quantities, and projected charges.
• Services Not Included: Identifies services that cannot reasonably be anticipated at the time of the estimate, including emergency services, hospitalization, testing, legal services, or services provided by other healthcare professionals.
• Potential Additional Charges: Provides space to document possible charges related to testing, crisis services, missed appointments, record requests, court-related services, paperwork, and other practice-specific fees.
• Payment Information: Documents accepted payment methods, payment timing, sliding scale availability, and payment plan options.
• No Surprises Act Dispute Rights: Includes required information regarding the client’s right to dispute a bill that exceeds the estimated cost by at least $400.
• Client and Provider Acknowledgment: Includes signature sections confirming the client received the estimate, had an opportunity to ask questions, and understands the expected charges.

How This Counseling Good Faith Estimate Form Functions in Practice

This form is designed to be completed before providing scheduled mental health services for clients who require a Good Faith Estimate. The completed document provides both the client and practice with a written record of the expected services and estimated costs communicated before treatment.

• Documents Expected Costs: Provides a structured summary of anticipated services, session frequency, CPT codes, and estimated charges.
• Supports Financial Transparency: Helps clients understand expected treatment expenses and potential additional charges before receiving services.
• Maintains Clinical Records: Creates documentation of the estimate provided, client acknowledgment, and provider signatures for practice records.
• Clarifies Additional Charges: Identifies services and fees that may occur but cannot reasonably be predicted when the estimate is created.

Documentation Features

• Comprehensive 3-page Good Faith Estimate template designed for mental health and counseling services.
• Documents provider information, client information, insurance status, and estimate details.
• Includes CPT code tracking, expected services, estimated quantities, and projected charges.
• Provides sections for potential additional charges and excluded services.
• Includes No Surprises Act dispute rights and client acknowledgment language.
• Documents payment information, signatures, and recordkeeping confirmation.

Practical Integration Notes

This template is intended to support documentation of expected costs for mental health services provided by counseling and behavioral health practices. Requirements related to Good Faith Estimates may vary based on client circumstances, payer status, state requirements, and applicable regulations. Mental health professionals should review current requirements and adapt this form to align with their practice policies and billing procedures.

References

• U.S. Department of Health and Human Services. (2022). No Surprises Act: Good Faith Estimates for Uninsured or Self-Pay Patients. https://www.cms.gov/files/document/gfe-and-ppdr-requirements-slides.pdf
• American Psychological Association. (2022). No Surprises Act Compliance for Psychologists. https://www.apaservices.org/practice/legal/managed/no-surprises-act