Quotation Estimate Psychologist in United States Houston –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation No.: QTE-2025-HOU-0347

Date Issued: June 12, 2025

Valid Until: July 12, 2025

Prepared By: Dr. Margaret Ellison, Ph.D., Licensed Psychologist

Client Information

Client Name: [Client Full Name]

Address: [Client Address], Houston, TX

Phone: [Client Phone Number]

Insurance Provider: [Insurance Company Name]

Dear Valued Client,

Thank you for considering Houston Behavioral Health Associates for your mental health and psychological services. This Quotation Estimate has been carefully prepared to outline the scope, duration, and associated costs of the Psychologist services we will provide to you here in United States Houston. Our team of board-certified and state-licensed professionals is dedicated to delivering compassionate, evidence-based psychological care tailored to your individual needs within the Houston, Texas metropolitan area.

The following Quotation Estimate covers a comprehensive package of psychological services to be delivered by a licensed Psychologist at our Houston, Texas office or via telehealth. All services are conducted in accordance with the Texas Occupations Code, Chapter 503, and the ethical standards of the American Psychological Association. The Psychologist assigned to your case will hold a Doctor of Philosophy (Ph.D.) or Doctor of Psychology (Psy.D.) degree and maintain active licensure with the Texas State Board of Examiners of Psychologists.

Item No.	Service Description	Duration / Frequency	Unit Rate (USD)	Estimated Total (USD)
1	Initial Comprehensive Psychological Assessment (includes clinical interview, cognitive testing, and personality evaluation)	3 hours (one-time)	$250.00	$750.00
2	Individual Psychotherapy Sessions (CBT, DBT, or psychodynamic approach as determined by the Psychologist)	50 min x 12 sessions	$185.00	$2,220.00
3	Psychological Testing and Diagnostic Evaluation (WAIS-IV, MMPI-2, or equivalent instruments)	2 hours (one-time)	$225.00	$450.00
4	Progress Review and Treatment Plan Adjustment (conducted by the supervising Psychologist)	30 min x 3 sessions	$120.00	$360.00
5	Written Psychological Report and Treatment Summary (for insurance, legal, or personal records)	One-time deliverable	$300.00	$300.00
6	Telehealth Consultation (secure video session with the Psychologist, available for clients across the Houston, TX area)	50 min x 4 sessions	$165.00	$660.00
7	Emergency After-Hours Consultation (limited to 2 instances within the treatment period)	30 min x 2 sessions	$150.00	$300.00
TOTAL ESTIMATED COST (Before Insurance Reimbursement)				$5,040.00

This Quotation Estimate reflects the standard fee schedule for Psychologist services in United States Houston. If you hold a valid health insurance policy that covers outpatient mental health services, a portion of the above costs may be reimbursed. Our billing department will submit claims on your behalf to your insurance provider. Please note that co-pays, deductibles, and out-of-network charges are the responsibility of the client. Payment is due within 30 days of the date of service. We accept Visa, Mastercard, American Express, HSA/FSA cards, and personal checks. A 1.5% monthly late fee will be applied to balances exceeding 30 days past due.

This Quotation Estimate is valid for 30 calendar days from the date of issuance. After the expiration date, fees may be subject to revision based on current market rates for Psychologist services in the United States Houston region.
All psychological services will be provided by a licensed Psychologist or under the direct supervision of one. No services will be delegated to unlicensed personnel.
Client confidentiality is maintained in strict accordance with HIPAA (Health Insurance Portability and Accountability Act) regulations and Texas state privacy laws. Records will be stored securely at our Houston, TX facility for a minimum of seven (7) years.
Cancellations must be made at least 24 hours in advance. Late cancellations or no-shows will be billed at 50% of the session fee.
The Psychologist reserves the right to modify the treatment plan based on clinical judgment. Any additional sessions beyond those listed in this estimate will be billed at the standard per-session rate and require prior written authorization from the client.
This estimate does not constitute a guarantee of specific therapeutic outcomes. Psychological treatment is a collaborative process, and progress varies among individuals.
By signing below, the client acknowledges receipt of this Quotation Estimate and agrees to the terms outlined herein for the provision of Psychologist services in United States Houston.

I, the undersigned client, have reviewed this Quotation Estimate for Psychologist services to be rendered in United States Houston. I understand the scope of services, associated costs, and terms outlined above. I authorize Houston Behavioral Health Associates to proceed with the described treatment plan upon my written or electronic acceptance.

Client Signature
Name: _________________________
Date: _________________________ Psychologist / Authorized Representative
Name: Dr. Margaret Ellison, Ph.D.
Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX

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