Good Faith Estimate Notice

Restoring Harbor Counseling, LLC
Effective Date: 06/01/2025

Under the law, health care providers are required to give patients who do not have insurance or who are not using insurance an estimate of the expected charges for medical services, including mental health care.

This is called a Good Faith Estimate and is provided under the No Surprises Act.

Your Right to a Good Faith Estimate

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy or counseling services.

The Good Faith Estimate will include:

• The type and frequency of services reasonably expected,

• The estimated total costs of services provided by Restoring Harbor Counseling, LLC,

• Any additional potential charges (e.g., late cancellation fees, documentation requests, etc., if applicable).

This estimate is not a contract or guarantee. Your actual costs may vary depending on your needs, progress in therapy, or any changes you request to the services provided.

When You’ll Receive the Estimate

• You have the right to request a Good Faith Estimate before you schedule a service.

• If you schedule services at least 3 business days in advance, you will receive the estimate within 1 business day.

• If you schedule services at least 10 business days in advance, you will receive the estimate within 3 business days.

Dispute Resolution

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

You may contact the provider directly to resolve the difference or initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS). There is a $25 fee to use this dispute process.

To learn more or start a dispute, visit:
www.cms.gov/nosurprises

Contact for Questions or More Information

Restoring Harbor Counseling, LLC
Jessica Gutierrez Gaytan, SWC
(970)691-2415
contact@restoringharbor.com