Notification of Good Faith Estimate

Effective January 1, 2022, a federal ruling went into effect called the “No Surprises Act,” which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) of costs to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for specific health care services.  We are also required to notify you of your right to a GFE in session (verbally) and to attempt to answer any questions you may have. Each client’s GFE is included in their intake packet .

You are entitled to receive a “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, the estimate given at intake 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.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in a good faith estimate. You have the 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).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

Notice to Clients

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of clinical social workers. You may contact the board online at ww.bbs.ca.gov, or by calling (916) 574-7830.

Teva Shinault Johnstone Licensed Clinical Social Worker No. 103826

License expiration date: September 30th, 2025