GOOD FAITH ESTIMATE/NO SURPRISE ACT

Intentional Therapy PLLC
Effective Date: October 22, 2025
Last Updated: October 22, 2025

INTRODUCTION

The estimate below is the range of costs that is likely for most new patients. Until your therapist does an initial evaluation and you start to work together, your therapist will not have a clear picture of your specific diagnosis, issues, and needs. Your therapist typically sees therapy clients for 8-12 sessions for a total cost of $1,040-$1,800. But in some cases, a client’s issues may be more complicated, so you and your therapist may need additional sessions during the time covered by this estimate. 

Brief explanation for continuing patients: The estimate below is the range of cost that we think is likely for your care over the time period covered by this estimate.  However, depending on how treatment progresses, more or fewer sessions may be needed. 

Contact Information for Privacy Inquiries:
Email: info@intentionaltherapypllc.com
Phone: (214) 506-8096

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for the services to address your mental health care needs. The estimate is based on the information known to us when we did the estimate. 

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.   

If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill

You may contact Intentional Therapy pLLC at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.  

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.  

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.  

To learn more and get a form to start the process, go to: 

www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

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

This GFE is not a contract.  It does not obligate you to accept the services listed above. 

Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.

To see more about your fees and services, click here.