ZOE Integrated Wellness, PLLC
Effective Date: [Insert Date]

Under the No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) explaining the expected cost of your mental health services.

1. Purpose of This Estimate

This GFE outlines the anticipated costs of services you may receive. Actual costs may vary depending on:

• Frequency of sessions

• Duration of treatment

• Changes in your treatment plan

2. Client Information

Client Name: __________________________
Date of Birth: _________________________
Estimate Date: _________________________

3. Provider Information

Provider Name: _________________________
Practice: ZOE Integrated Wellness, PLLC
Email: zoewellness07@gmail.com
Phone: 928-395-5803
Address: 1748 Leisure World, Mesa, Az. 85206

 

4. Services & Estimated Costs

Service

CPT Code

Fee per Session

Estimated Annual Total*

Initial Intake Evaluation

90791

$________

$________

Individual Therapy (45–55 min)

90837/90834

$________

$________

Telehealth Therapy

Same as above

$________

$________

Other Services (specify)

______

$________

$________

*Annual totals are based on an estimated number of sessions (e.g., weekly, biweekly, monthly).
This is only an estimate, not a contract.

5. Disclaimer

• This estimate is not a guarantee of final charges.

• Additional services may be recommended as clinically appropriate.

• You may request an updated GFE at any time.

6. Acknowledgment

I acknowledge that I received and reviewed this Good Faith Estimate.

Client Signature: ___________________________
Date: ___________________