Good Faith Estimate

Original Effective Date: June 24, 2026; Updated August 23, 2026

If you are paying for therapy yourself, you have a federal right to know what it will cost before you begin — in writing, at no charge, and without having to ask twice.

Trellis Therapy of Loudoun, PLLC (referred to as “we,” “us,” “the Practice,” “Provider,” or “our” throughout this estimate) is a private-pay practice. We are out of network with all insurance plans, which means nearly every client here is entitled to a Good Faith Estimate. We provide one to every new client as part of intake, and to any current client who asks. We publish our fees here so you know what therapy costs before you reach out, and so you can weigh that against what your out-of-network benefits may reimburse.

Every person’s course of therapy is different. How long and how often you come is shaped by your schedule, therapist availability, what is going on in your life, and your finances. We talk about that openly, and we put it in writing in your Good Faith Estimate.

Your Right to a Good Faith Estimate

Under Section 2799B-6 of the Public Health Service Act, health care providers must give individuals who are uninsured or who are not using insurance benefits a Good Faith Estimate of expected charges for non-emergency services.

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

This estimate is not a contract and does not require you to obtain services. No payment is required to receive it. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Provider Information

Client name: ______________________________  Date of birth: ____________

Date this estimate was issued: ____________     Client scheduled on: ____________

Where services will be provided:

☐ In person — 20915 Ashburn Road, Suite 215, Ashburn, VA 20147
☐ Online, by telehealth (Zoom)

Diagnosis Codes

Diagnosis codes are determined following assessment and may change as treatment progresses. Common examples at this practice:

F32.9 — Major depressive disorder, unspecified

F41.1 — Generalized anxiety disorder

F43.10 — Post-traumatic stress disorder, unspecified

F43.23 — Adjustment disorder with mixed anxiety and depressed mood

Z65.9 — Problem related to unspecified psychosocial circumstances

Listed for informational purposes; your actual diagnosis code will be determined after assessment.

Diagnosis code(s) applicable to this estimate: ______________________________

Estimated Services and Charges

Service CPT Session Length Fee__
Initial diagnostic evaluation 90791 Typically 60 minutes $225
Psychotherapy session 90837 53 minutes or more $200
Psychotherapy session 90834 38–52 minutes $175
Psychotherapy session 90832 16–37 minutes $150
Family therapy, client present 90847 50 minutes or more $200
Family therapy, client not present 90846 50 minutes or more $200
Administrative services Per 15 minutes $75
(letters, reports, consultation with
another provider, etc.)
Court testimony and legal services Per hour, two-hour $500
minimum retainer
paid in advance

Total estimated cost for the period covered: $____________

The estimate above assumes weekly sessions at the standard rate. Not everyone meets weekly. We will discuss your specific needs as we go.

Assumptions and Limits

Session frequency may be weekly, twice-weekly, or biweekly depending on clinical need and progress, and may change over time.

This estimate reflects services reasonably expected at the time it was issued. It is not a guarantee of the number of sessions that will occur or of the final amount you will owe.

This estimate does not include administrative services, crisis sessions, legal or court fees, care coordination with other providers, late cancellation fees, or missed appointment fees. These items would require separate scheduling, and separate Good Faith Estimates would need to be requested for them.

• If a payment is declined or returned for insufficient funds, a $75.00 failed payment fee per occurrence is added to your balance to cover bank charges and administrative time.

• If you cancel with less than 48 hours' notice, or do not attend a scheduled appointment, you will be charged the full session fee.

Fees are subject to annual adjustment, typically effective January 1, with at least 30 days' written notice.

Actual services may differ based on clinical needs and decisions made collaboratively between you and your clinician.

A new Good Faith Estimate will be provided if your treatment plan changes significantly, or at your request at any time.

Your Right to Dispute a Bill

If you are billed $400 or more above the total on this Good Faith Estimate, you have the right to dispute the bill through the federal patient-provider dispute resolution process.

You must start the dispute within 120 calendar days of the date on your original bill. There is a small administrative fee to use the process, which may be reduced or waived for individuals below an income threshold. The current amount is published by CMS.

If the reviewer decides in your favor, you pay the price on this Good Faith Estimate. If the reviewer decides in the provider's favor, you pay the billed amount. Starting a dispute will not adversely affect the quality of your health care services, and we will not retaliate.

You may also simply contact us first — you can ask us to update the bill to match the estimate, ask to negotiate, or ask whether financial assistance is available. We would rather resolve it directly.

To learn more or start a dispute: visit cms.gov/nosurprises or call 1-800-985-3059.

Please keep a copy or photo of this Good Faith Estimate.

Accessible formats. If you need this estimate, or any of our forms, in large print, in another language, read aloud, or in another accessible format, contact us. There is no charge.

Client Acknowledgment

By signing below, I acknowledge that I received and reviewed this Good Faith Estimate before my first scheduled service, and that it is an estimate of expected costs — not a bill, and not a guarantee of the final amount I will owe.

This notice is provided under Section 2799B-6 of the Public Health Service Act and its implementing regulations at 45 C.F.R. § 149.610; the dispute resolution process described above is set out at 45 C.F.R. § 149.620.