GOOD FAITH ESTIMATE
Provider Name: Erin Esther Ratcliff
License/#: LMFT 105831
Provider Address: 3941 Park Drive Suite 20-474 El Dorado Hills, CA 95762
Provider Phone #/email: (916) 672.7137 erinratclifflmft@gmail.com
Provider Tax ID# (if applicable): 85-1044097
Provider NPI # (if applicable): 103347303
Patient Name:
Patient Address:
Patient Phone #: ( )
Patient Email:
Patient Diagnosis (if known/applicable):
Services Requested:
You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $120. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $120 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $480 for four visits provided over the course of one month; $960 for eight visits over two months; or $1440 for 12 visits over three months. If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.
The fee for a 50-minute psychotherapy visit (in person or via telehealth) is $120. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on a fee of $120 per visit, the following are expected charges of psychotherapy services:
Number of Weeks
1 Week of Service
$120 Total estimated charges for 1 session per week
$240 Total estimated charges for 2 sessions per wee
13 Weeks of Service (Approx. 3 Months)
$1560 Total estimated charges for 1 session per week
$3120 Total estimated charges for 2 sessions per wee
26 Weeks of Service (Approx. 6 months)
$3120 Total estimated charges for 1 session per week
$6240 Total estimated charges for 2 sessions per wee
39 Weeks of Service (Approx. 9 months)
$4680 Total estimated charges for 1 session per week
$9360 Total estimated charges for 2 sessions per wee
52 Weeks of Service (Approx. 12 Months)
$6240 Total estimated charges for 1 session per week
$12480 Total estimated charges for 2 sessions per week
You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.
Date of this Estimate _________________________________________________
*This estimate is unofficial if unsigned by provider and client.