Quotation Estimate Psychologist in United States New York City –Free Word Template Download with AI

This Quotation Estimate is issued by Dr. Eleanor M. Whitfield, a fully licensed and board-certified Psychologist operating in the United States New York City metropolitan area, to provide a comprehensive and transparent breakdown of professional psychological services. This document serves as a formal cost projection for the requested scope of psychological care, assessment, and therapeutic intervention. All pricing reflected in this Quotation Estimate complies with the New York State Education Department regulations governing the practice of psychology and adheres to the ethical standards set forth by the American Psychological Association (APA).

The following services have been outlined based on the initial consultation and clinical needs assessment conducted on June 5, 2025. As a practicing Psychologist in the United States New York City region, Dr. Whitfield offers a full spectrum of evidence-based interventions tailored to the individual or organizational client.

This Quotation Estimate is valid for a period of ninety (90) days from the date of issue. Payment is due within fifteen (15) business days of the invoice date. Accepted payment methods include ACH bank transfer, certified check, and major credit cards (Visa, Mastercard, American Express). A non-refundable deposit of twenty percent (20%) of the total estimated amount is required to secure the client's appointment schedule with the Psychologist. All fees are subject to the prevailing New York State fee schedule for licensed psychologists and may be adjusted annually in accordance with the New York State Board of Psychology guidelines.

Dr. Whitfield participates in the following insurance networks serving the United States New York City area: Aetna, Cigna, UnitedHealthcare, Empire BlueCross BlueShield, and New York State Employee Health Plan. This Quotation Estimate reflects standard out-of-pocket rates. If the client's insurance plan covers psychological services, the Psychologist's office will submit claims on the client's behalf. The client is responsible for any co-pays, deductibles, or amounts exceeding the insurance allowable. A superbill will be provided for out-of-network reimbursement purposes.

The undersigned Psychologist holds a Doctor of Philosophy (Ph.D.) in Clinical Psychology from Columbia University, New York, and maintains an active license to practice psychology in the State of New York (License No. PSY-118472). All services described in this Quotation Estimate are delivered in full compliance with the New York State Education Law, the Health Insurance Portability and Accountability Act (HIPAA), and the ethical code of the American Psychological Association. Confidentiality is maintained in accordance with 42 CFR Part 2 and New York State Mental Hygiene Law Section 33.13.

Clients are requested to provide a minimum of twenty-four (24) hours' notice for any cancellation or rescheduling of a session. Cancellations made within twenty-four hours of the scheduled appointment will incur a fee of fifty percent (50%) of the session rate. No-show appointments will be billed at the full session rate. This policy applies to all in-person and telehealth sessions conducted by the Psychologist in the United States New York City practice location.