Good Faith Estimate

Effective Date:12/14/2025

Your Rights and Protections Against Surprise Medical Bills

Under the federal No Surprises Act, you have the right to receive a "Good Faith Estimate" of expected charges before you receive mental health services from The Nickel Collective.

This notice applies to self-pay clients (those who are not using insurance to pay for services).

What is a Good Faith Estimate?

A Good Faith Estimate is an estimate of the expected cost of your mental health care services. This estimate is based on information known at the time it's created and may change based on your specific circumstances.

You have the right to receive a Good Faith Estimate:

  • When you schedule a service, or

  • Upon request

Good Faith Estimate for Therapy Services

Individual Therapy Sessions

Service: Individual Psychotherapy (50-minute session)
Cost per Session: $185

Expected Frequency:

  • Weekly sessions: Most common during active treatment

  • Bi-weekly sessions: As you make progress and build sustainable systems

  • Monthly sessions: For maintenance or ongoing support

Example Cost Estimates

3-Month Treatment Period (Active Treatment):

  • Weekly sessions: 12-13 sessions × $185 = $2,220 - $2,405

  • Bi-weekly sessions: 6-7 sessions × $185 = $1,110 - $1,295

6-Month Treatment Period:

  • Weekly sessions: 24-26 sessions × $185 = $4,440 - $4,810

  • Bi-weekly sessions: 12-13 sessions × $185 = $2,220 - $2,405

  • Transitioning frequency: ~18-20 sessions × $185 = $3,330 - $3,700

12-Month Treatment Period:

  • Weekly to bi-weekly to monthly: ~30-40 sessions × $185 = $5,550 - $7,400

Initial Clarity Call

Service: Free 15-minute clarity call
Cost: $0 (No charge)

Important Information About This Estimate

This is an estimate only. Your actual costs may be higher or lower depending on:

  • How frequently you attend sessions

  • The length of time you're in therapy

  • Your specific treatment needs and goals

  • Whether you cancel or reschedule appointments (late cancellation fees may apply)

  • Any additional services you request

Treatment length varies. Some clients see significant improvement in 3-4 months. Others work with me for a year or longer to create deeper, lasting change. We'll check in regularly about your progress and adjust frequency as needed.

You're in control. You decide how often to attend sessions and how long to continue therapy. There is no minimum commitment or required number of sessions.

Additional Fees That May Apply

Late Cancellation Fee:
If you cancel or reschedule with less than 24 hours' notice, you may be charged a late cancellation fee (typically the full session fee of $185).

Returned Payment Fee:
If a payment is returned or declined, a processing fee may apply.

Additional Services:
Any services beyond standard 50-minute therapy sessions (such as extended sessions, letters, or other documentation requests) will be discussed and agreed upon in advance.

Payment Information

Payment is due at the time of service.

Accepted Payment Methods:

  • Credit cards

  • Debit cards

Insurance:

  • We do not accept insurance directly

  • We provide superbills for out-of-network reimbursement if requested

HSA/FSA:

  • Not accepted directly at this time

  • You may be able to seek reimbursement on your own (therapy is typically an eligible expense)

Your Rights Under the No Surprises Act

You have the right to:

  1. Receive this Good Faith Estimate before services are provided or upon request

  2. Receive an updated Good Faith Estimate if your treatment plan changes significantly

  3. Ask questions about the estimate and your expected costs

  4. Dispute charges if your final bill is substantially higher than the Good Faith Estimate (see below)

How to Dispute a Bill

If your actual charges are $400 or more higher than the Good Faith Estimate you received, you have the right to dispute the bill.

To initiate a dispute:

You must contact the Patient-Provider Dispute Resolution (PPDR) process within 120 days of receiving your bill.

Contact information for PPDR:

  • Website: https://www.cms.gov/nosurprises/policies-and-resources/patient-provider-dispute-resolution

  • Phone: 1-800-985-3059

  • Online Portal: Available through the CMS website

What you'll need:

  • A copy of your Good Faith Estimate

  • A copy of your final bill

  • Explanation of why you believe the charges are substantially different

Asking Questions About Your Estimate

If you have questions about your Good Faith Estimate or expected costs, please contact us:

The Nickel Collective
Katie Nickel, LPC-IT
13160 W. Burleigh Rd.
Brookfield, WI 53005

hello@thenickelcollective.com

We're happy to:

  • Explain your Good Faith Estimate

  • Provide an updated estimate if your treatment plan changes

  • Answer questions about fees, payment, or billing

  • Discuss payment options or concerns

When You'll Receive a Good Faith Estimate

You will receive a Good Faith Estimate:

  • Before your first therapy session (included in your intake paperwork)

  • Upon request at any time

  • If your treatment plan changes significantly (e.g., moving from weekly to monthly sessions)

How you'll receive it:

  • Through our secure client portal

  • Via email (upon request)

  • In paper form (if preferred)

Important Reminders

This estimate is not a contract or guarantee of final charges. It is based on the information available at the time it's created.

You are not required to accept this estimate or proceed with services. You have the right to shop around and compare costs with other mental health providers.

Therapy is a collaborative process. We'll regularly discuss your progress, treatment goals, and whether continuing therapy is the right choice for you.

State-Specific Information (Wisconsin)

In addition to federal protections under the No Surprises Act, Wisconsin law provides additional consumer protections for healthcare services. If you have questions about your rights under Wisconsin law, you may contact:

Wisconsin Department of Health Services
Website: https://www.dhs.wisconsin.gov
Phone: (608) 266-1865

More Information About the No Surprises Act

For more information about your rights under the No Surprises Act, visit:

  • Centers for Medicare & Medicaid Services: https://www.cms.gov/nosurprises

  • U.S. Department of Health & Human Services: https://www.hhs.gov/hipaa/for-professionals/special-topics/no-surprises-act/index.html

Questions?

If you have any questions about this Good Faith Estimate, your expected costs, or your rights, please don't hesitate to contact us. We're committed to transparency about fees and want you to feel confident about the financial aspects of therapy.

The Nickel Collective
Licensed Professional Counselor in Training (LPC-IT) in Wisconsin
Brookfield, Wisconsin

This Good Faith Estimate notice was last updated on 12/14/2025 and complies with the federal No Surprises Act (effective January 1, 2022).

LEGAL NOTICE

This Good Faith Estimate template is provided for informational purposes and should be reviewed by a healthcare attorney to ensure full compliance with the No Surprises Act and Wisconsin state law. The Nickel Collective assumes no liability for your use of this template.