Copyable Good Faith Estimate Template for Therapy Services
Use this Good Faith Estimate template as a starting point for uninsured or self-pay clients who need expected cost information before behavioral health services begin. Copy it into your EHR, intake packet, secure client portal, or practice management system, then adjust the language, service names, fees, and timing to match your practice.
This template is written for therapists, counselors, social workers, psychologists, psychiatrists, and other behavioral health clinicians. It is not legal advice, and it should be reviewed against your current federal, state, payer, and professional requirements before use.
Good Faith Estimate Template
Good Faith Estimate for Behavioral Health Services
Client Name: [Client full name]
Date of Birth: [MM/DD/YYYY]
Client Contact Information: [Phone, email, mailing address]
Date Estimate Prepared: [MM/DD/YYYY]
Estimated Service Period: [Start date through end date, if known]
Provider / Practice Name: [Practice or clinician name]
Provider Type and Credentials: [LCSW, LPC, LMFT, PhD, PsyD, MD, NP, etc.]
NPI: [Individual or organization NPI, if applicable]
Tax ID: [If applicable]
Practice Address: [Street, city, state, ZIP]
Practice Contact: [Phone and email]
Client Status: This estimate is being provided because the client is uninsured, is not using insurance benefits for these services, or has requested a Good Faith Estimate.
Estimated Services and Fees
| Service | Service Code | Estimated Frequency | Fee Per Service | Estimated Total |
|---|---|---|---|---|
| [Initial intake / diagnostic assessment] | [Code, if used] | [1 session] | [$___] | [$___] |
| [Individual psychotherapy, 45 or 53+ minutes] | [Code, if used] | [__ sessions per __] | [$___] | [$___] |
| [Family therapy / group therapy / medication management / testing, if applicable] | [Code, if used] | [As clinically indicated] | [$___] | [$___] |
Estimated Total Cost: [$___]
How this estimate was calculated: This estimate is based on the services currently expected, the provider’s current private-pay fees, and the anticipated frequency of care. Actual services may change based on client needs, clinical presentation, scheduling, treatment goals, cancellations, or changes requested by the client.
Services not included in this estimate: This estimate does not include services not currently scheduled or anticipated, such as additional assessments, psychological testing, coordination with outside providers, court-related services, report writing, missed appointment fees, records fees where allowed, or services provided by other clinicians or organizations.
Client rights and questions: If the actual billed charges are substantially higher than this estimate, the client may have rights under applicable surprise billing and Good Faith Estimate rules. The client may contact the practice with questions about this estimate before services are provided.
Provider Signature: ___________________________
Date: ___________________________
Completed Good Faith Estimate Example for a Private-Pay Therapy Client
Here is a completed sample for a self-pay adult client beginning individual therapy. The numbers are examples only. Replace them with your practice’s actual fees, service names, and expected care plan.
Client Name: Jordan Lee
Date of Birth: 04/12/1992
Date Estimate Prepared: 02/03/2026
Estimated Service Period: 02/10/2026 through 05/10/2026
Provider / Practice Name: North Valley Counseling, PLLC
Provider Type and Credentials: Maria Carter, LCSW
NPI: 1234567890
Practice Contact: 555-0100, intake@examplepractice.com
| Service | Service Code | Estimated Frequency | Fee Per Service | Estimated Total |
|---|---|---|---|---|
| Initial diagnostic assessment | 90791 | 1 session | $180 | $180 |
| Individual psychotherapy, 53+ minutes | 90837 | 10 sessions | $150 | $1,500 |
| Care coordination, if requested and clinically appropriate | N/A | Up to 2 units | $50 | $100 |
Estimated Total Cost: $1,780
How this estimate was calculated: This estimate assumes one intake session followed by approximately ten weekly individual therapy sessions over three months. The actual number of sessions may increase or decrease based on treatment goals, client preference, clinical need, attendance, and scheduling.
Services not included: Psychological testing, court testimony, written reports, missed appointment fees, services from other providers, higher levels of care, emergency services, and services not currently planned are not included in this estimate.
When Behavioral Health Practices Use a Good Faith Estimate
A Good Faith Estimate is commonly used when a client is uninsured, chooses not to use insurance, or asks for an estimate before starting or continuing services. In behavioral health, this often comes up during intake, before a private-pay evaluation, or when a client changes from insurance billing to self-pay.
Common therapy practice scenarios include:
- A new self-pay client schedules an initial diagnostic assessment.
- A client with insurance chooses not to submit claims for privacy or deductible reasons.
- A clinician provides a planned package of psychological testing or assessment services.
- A client asks for an expected cost range before committing to weekly therapy.
For many practices, the GFE fits naturally into the intake workflow. The admin team or clinician confirms the client’s payment status, reviews the expected service type, enters the current fee schedule, and sends the estimate before the first scheduled service when required. The estimate should be understandable to the client, not written only for billing staff.
What to Include in a Therapy Good Faith Estimate
A useful GFE should give the client enough information to understand the likely cost of care. It does not need to predict every future clinical decision, but it should reflect the services you reasonably expect at the time you prepare it.
Include these core details:
- Client and provider information: Name, contact information, provider credentials, NPI when applicable, and practice address.
- Service details: Intake, individual therapy, group therapy, family therapy, medication management, testing, or other expected services.
- Estimated charges: Fee per service, expected frequency, estimated number of sessions, and estimated total cost.
- Plain-language limitations: A short explanation that actual services may change based on clinical need, scheduling, and client choice.
Some practices also include CPT codes or internal service codes. That can be helpful, especially when clients are comparing insurance reimbursement options or requesting superbills. If codes are included, make sure staff understand that the code should match the service actually provided and documented.
How to Adapt the Template for Common Behavioral Health Services
A single template can work across several service types if your practice keeps the service descriptions clear. The goal is to avoid vague labels like “therapy services” when the expected service is more specific.
Individual therapy
For ongoing therapy, list the intake separately from follow-up sessions. If the client is expected to attend weekly sessions for 12 weeks, show the per-session fee and estimated total for 12 sessions. You can also state that the care plan may be revisited after the initial treatment period.
Group therapy
Group therapy estimates should identify the group type, expected number of sessions, and per-group fee. If the group has a fixed length, such as eight sessions, the estimate can be more specific. If it is an open group, describe the expected period covered by the estimate.
Assessment and testing
Assessment services often include several components: clinical interview, test administration, scoring, interpretation, feedback session, and written report. Separate those items when your pricing structure allows. This helps clients understand why an assessment may cost more than a single therapy visit.
Psychiatry and medication management
For psychiatric services, separate the initial evaluation from follow-up medication management visits. If additional coordination, forms, or records review may carry a fee, state that clearly if your practice charges for those services.
Common Good Faith Estimate Mistakes to Avoid
Most GFE problems are not caused by bad intent. They usually happen because the practice uses an outdated fee schedule, leaves out a planned service, or sends a generic form that does not match the client’s care.
- Using one estimate for every client: A weekly therapy client, testing client, and medication management client may need different service lines.
- Forgetting to update fees: If your private-pay rate changes, update the template, intake forms, website fee page, and saved snippets.
- Overpromising precision: A GFE is an estimate. Avoid wording that suggests the total will never change.
- Leaving out non-session fees: If your practice charges for reports, letters, missed appointments, or extended coordination, explain when those fees may apply.
Another common issue is storing estimates outside the rest of the client record. If the GFE is sent by email, generated in a separate document app, or prepared by an intake coordinator, make sure your team knows where the final version belongs. A consistent filing process can reduce confusion later.
Good Faith Estimate Workflow for Small Practices
Solo and small group practices do not need an overly complex process. They do need a repeatable one. A simple workflow helps the practice send estimates consistently, answer client questions, and document what was provided.
- Confirm payment status: Ask whether the client is uninsured, using insurance, or choosing self-pay.
- Select the correct service type: Intake, therapy, group, testing, psychiatry, or another service.
- Enter expected frequency and fees: Use your current private-pay fee schedule.
- Send and save the estimate: Provide it through your normal secure process and store a copy in the client record.
If your team has more than one person handling intake, assign ownership. For example, the intake coordinator prepares the GFE, the clinician reviews unusual cases, and the practice owner updates the fee schedule quarterly. That division keeps the process manageable without relying on memory.
How AutoNotes Helps With Documentation Templates
AutoNotes helps behavioral health professionals create structured, editable documentation drafts faster. While a Good Faith Estimate is an administrative document rather than a progress note, many of the same workflow problems apply: repeated text, inconsistent formatting, missing fields, and too much after-hours cleanup.
With AutoNotes, clinicians can work from service-specific templates for common behavioral health documentation needs, including intake sessions, assessments, treatment planning, group therapy, and progress notes. The clinician stays in control by reviewing, editing, and finalizing each draft before it becomes part of the record.
For practices trying to tighten documentation habits, AutoNotes can help by:
- Creating structured drafts: Turn session details into organized note sections such as interventions, client response, progress, and plan.
- Reducing repetitive writing: Use templates that match the service type instead of starting from a blank page.
- Improving consistency: Keep note structure more predictable across sessions and clinicians.
- Supporting clinician review: Edit every draft before finalizing so clinical judgment remains with the provider.
If documentation is spilling into evenings or weekends, consider testing a faster note workflow alongside your administrative templates. Start your free trial and see how AutoNotes fits your practice before making a longer-term decision.
Good Faith Estimate FAQ for Therapists
Is a Good Faith Estimate the same as a treatment plan?
No. A treatment plan documents clinical goals, interventions, frequency, and the direction of care. A Good Faith Estimate focuses on expected charges for services. The two documents may reference similar services, but they serve different purposes.
Do I need a new estimate every session?
Usually, practices create an estimate for an expected course or period of care, then update it when the expected services, frequency, or fees materially change. Your practice should follow current rules and any applicable state or payer requirements.
Should CPT codes be included?
Many practices include CPT codes because they clarify the service being estimated. If you include them, use codes carefully and make sure the billed service matches the service actually provided and documented.
Can I use this template for insured clients?
You can adapt the format for cost discussions, but federal GFE obligations are most commonly tied to uninsured and self-pay individuals. Insurance estimates may involve different information, including benefits, deductibles, copays, coinsurance, and payer rules.
Does AutoNotes create final Good Faith Estimates automatically?
AutoNotes is designed to help clinicians create editable documentation drafts and templates faster. Any GFE, progress note, or clinical document should be reviewed and finalized by the provider or practice according to current requirements and internal policy.
Use This Template as Part of a Cleaner Documentation Process
A Good Faith Estimate works best when it is specific, current, and easy for the client to understand. Start with the copyable template above, customize it for your services, and build it into your intake process so it is not recreated from scratch each time.
For the clinical side of documentation, AutoNotes gives therapists and behavioral health professionals a faster way to create structured, editable progress note drafts. Try it free and keep your review, edits, and clinical judgment at the center of the final note.
