The Good Faith Estimate

Effective Date: October 5th, 2026

At Therapy With Manon, we believe that you should have clear information about the expected cost of your mental health services before beginning treatment. Under applicable federal law, including the No Surprises Act, individuals who are uninsured or who are not using insurance to pay for healthcare services may be entitled to receive a Good Faith Estimate of expected charges.

What Is a Good Faith Estimate?

A Good Faith Estimate is an estimate of the expected charges for scheduled healthcare services. For therapy and behavioral health services, the estimate may include the expected cost of psychotherapy sessions and other services that are reasonably expected to be provided as part of your course of care. Because therapy is individualized and treatment needs can change over time, a Good Faith Estimate is based on the information reasonably available to us when the estimate is prepared. A Good Faith Estimate is not a guarantee of the total amount you will ultimately pay.

Who May Receive a Good Faith Estimate?

Generally, Good Faith Estimates are available to individuals who are uninsured or choosing not to submit claims to their health insurance for the services being provided.

What Will My Estimate Include?

When applicable, your Good Faith Estimate may include information such as: the expected type of service; the expected number or frequency of sessions; the estimated charge for each service; the estimated total expected charges for the period covered by the estimate; and other reasonably expected charges associated with the services. Because mental health treatment is individualized, the frequency and duration of therapy may change based on your clinical needs and treatment goals. If the scope or expected duration of treatment changes materially, you may request an updated estimate.

Your Right to Receive a Good Faith Estimate

You have the right to receive a Good Faith Estimate of expected charges before scheduling. Once you have a consultation, your therapist will give you a Good Faith Estimate to sign before conducting any therapeutic services. For scheduled services, a Good Faith Estimate will generally be provided within the timeframes required by applicable law.

Your Right to Dispute Certain Charges

If you are uninsured or are not using insurance to pay for your healthcare services, and you receive a bill that is substantially higher than the Good Faith Estimate provided to you, federal law may provide you with certain rights to dispute the bill. If you believe that a bill is substantially higher than your Good Faith Estimate, you may have the right to request a review or dispute the charge through the applicable federal process. Additional information about the federal patient-provider dispute process is available from the U.S. Centers for Medicare & Medicaid Services (CMS).

Important Information About Estimates

A Good Faith Estimate is an estimate, not a contract or guarantee of treatment. The actual services you receive may differ from the services included in an estimate. Changes may occur because of clinical needs, treatment preferences, scheduling, changes in the course of therapy, or other circumstances. An estimate does not require you to continue treatment for the entire estimated period. Likewise, receiving an estimate does not guarantee that Therapy With Manon will be able to provide every service identified in the estimate.

Questions About Your Estimate

If you have questions about a Good Faith Estimate or believe that the services or charges on your estimate do not accurately reflect the services you are scheduled to receive, please contact us before your appointment whenever possible.

Therapy With Manon
424-337-0696
manon@therapywithmanon.com

Federal Notice

For additional information regarding your rights under the No Surprises Act and the federal Good Faith Estimate requirements, please visit the official CMS website at https://www.cms.gov/nosurprises or call 800-985-3059. 

Please note: The Good Faith Estimate requirements and applicable exceptions may depend on Therapy With Manon reserves the right to update this notice as applicable laws and regulations change.