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SERVICES
We believe in addressing all areas of your life:
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Our focus is to help you develop practical, realistic, and effective strategies for more successful living.
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Impact counselors are available to help young children (play therapy); older children, teenagers, and adults (individual counseling); engaged couples (premarital); married couples (marriage counseling); and family systems (family counseling).
mental
physical
emotional
spiritual
COUNSELING SERVICES
PLAY THERAPY
for young children
.Adults can convey how they think and feel with words and phrases however, that can be a difficult task for children. Play is a child’s natural mode of expression, therefore, we utilize play to help children express thoughts and communicate feelings more easily and safely through toys, games, art, books and other play activities.
INDIVIDUAL
COUNSELING
for older children, teens and adults
PREMARITAL
COUNSELING
We are registered with Twogether in Texas, a program that discounts your marriage license.
PREMARITAL
MARRIAGE
COUNSELING
FAMILY
COUNSELING
FEES AND POLICIES
Insurance Information
We have counselors who are in-network with Blue Cross Blue Shield of Texas and Aetna. We will soon be adding other insurance providers.
Please note that mental health benefits often differ from medical benefits—copays and coverage may not be the same. In some cases, mental health services are managed by a separate company contracted by your insurance provider.
While we make every effort to verify your benefits, this is not a guarantee of coverage. Final determination often depends on your diagnosis and the specific services provided. In many cases, we will not know exactly what your insurance will cover until the first session is submitted and processed by your insurance company.
​No Surprise Act Good Faith Estimate
Impact Counseling and Guidance Center
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care
facilities are required to provide a good faith estimate of expected charges for items and services
to individuals who are not enrolled in a plan or coverage of a Federal health care program, or
who are not seeking to file a claim with their plan or coverage. This document describes your
protections against unexpected health care bills. It also asks if you would like to give up those
protections and pay for out-of- network care.
If you would like assistance with this document, speak with an Impact Counseling and Guidance
Center Client Representative.
This is an estimate of what you could pay if you choose to not utilize your
insurance plan to cover costs of counseling.
â–ºReview your good faith estimate of expected costs. See cost estimate for services rendered
below.
â–ºCall your health plan. Your health care plan may cost you less. Ask your health care provider
what is covered under your plan and what your provider options are.
â–ºQuestions about this notice and estimate? Contact an Impact Counseling and Guidance
Center Administrative Assistant
â–ºQuestions about your rights? Contact 1-800-985-3059
Prior authorization or other care management limitations
Except in an emergency, if you have a health care plan it may require prior authorization (or
other limitations) for certain services. This means you may need your plan’s approval that it will
cover services before you receive them. If your plan requires prior authorization, ask them what
information they need for you to receive coverage.
Understand your options
Ask your health care provider what services are considered in-network with your health plan.
More information about your rights and protections
Visit www.cms.gov/nosurprises/consumers for more information about your federal law rights
Cost Estimates for Impact Counseling and Guidance Center
Services
The amounts and examples noted below are only an estimate and is not an offer or contract
for services. It does not include any information about what your insurance plan may cover
should you choose to personally apply for reimbursement with your insurance provider. Contact
your insurance provider to find out if your plan will pay any portion of these costs, and how
much you may have to pay out-of-pocket.
Individual, Marriage, and Family Sessions Provided by a Licensed
Mental Health Professional (LPC, LCSW, LMFT, Psychologist)
The fee for an intake session provided by a Licensed Mental Health Professional is $125 and
subsequent counseling sessions provided by a licensed professional are $115 per session. After
your intake session, your Provider can recommend an initial number of sessions and frequency of
sessions. In consultation with your Provider, the number and frequency of sessions often changes
over time.
However, you determine the number/frequency of sessions, not your Provider.
A typical number of individual, marriage and family sessions would a single intake session,
followed by 4-6 counseling sessions.
Your typical estimated cost for 1 intake session would be $125.
Your typical estimated cost for 4 counseling sessions would be 4 x $115 = $460
Your typical estimated cost for 5 counseling sessions would be 5 x $115 = $575
Your typical estimated cost for 6 counseling sessions would be 6 x $115 = $690
Individual, Marriage, and Family Sessions Provided by a Licensed
Professional Counselor Associate
The fee for an intake session provided by a LPC Associate is $85 and subsequent counseling
sessions provided by a LPC Associate are $75 per session. After your intake session, your
Provider can recommend an initial number of sessions and frequency of sessions. In consultation
with your Provider, the number and frequency of sessions often changes over time.
However, you determine the number/frequency of sessions, not your Provider.
A typical number of individual, marriage and family sessions would a single intake session,
followed by 4-6 counseling sessions.
Your typical estimated cost for 1 intake session would be $85.
Your typical estimated cost for 4 counseling sessions would be 4 x $75 = $300
Your typical estimated cost for 5 counseling sessions would be 5 x $75 = $375
Your typical estimated cost for 6 counseling sessions would be 6 x $75 = $450
Individual, Marriage, and Family Sessions Provided by a Graduate
Student Counselor
The fee for an intake session provided by a Graduate Student Counselor is $65 and subsequent
counseling sessions provided by a Graduate Student Counselor are $55 per session. After your
intake session, your Provider can recommend an initial number of sessions and frequency of
sessions. In consultation with your Provider, the number and frequency of sessions often changes
over time.
However, you determine the number/frequency of sessions, not your Provider.
A typical number of individual, marriage and family sessions would a single intake session,
followed by 4-6 counseling sessions.
Your typical estimated cost for 1 intake session would be $65
Your typical estimated cost for 4 counseling sessions would be 4 x $55 = $220
Your typical estimated cost for 5 counseling sessions would be 5 x $55 = $275
Your typical estimated cost for 6 counseling sessions would be 6 x $55 = $330
Pastoral Counseling Sessions
The fee for an intake session provided by a pastoral counselor is $105 and subsequent
counseling sessions provided by a pastoral counselor are $95 per session. After your first
session, your Provider can recommend an initial number of sessions and frequency of
sessions. In consultation with your Provider, the number/frequency of sessions often
changes over time.
However, you determine the number/frequency of sessions, not your Provider.
A typical number of pastoral sessions would be a single intake session, followed by 4-6
counseling sessions.
Your typical estimated cost for 1 intake session would be $105
Your typical estimated cost for 4 counseling sessions would be 4 x $95 = $380
Your typical estimated cost for 5 counseling sessions would be 5 x $95 = $475
Your typical estimated cost for 6 counseling sessions would be 6 x $95 = $570
Pre-Marital Sessions
The session fee for pre-marital sessions is $80 per session. A typical number of single block premarital sessions is 8.
However, you determine the number/frequency of sessions, not your Provider.
Your typical estimated cost for 8 sessions would be 8 x $80 = $640
Payment for Services
You are responsible for full payment of fees at the time of each session. We accept Cash, Checks,
Visa, MasterCard, American Express, Discover, Flex Spending and HSA cards.
We require a credit card on file for electronic payments toward in-person sessions, telehealth
sessions, phone sessions, unpaid balances, and collecting payments toward non-service charges
like no shows, late cancellation fees, and legal expenses incurred.
It is your responsibility to inform us of any changes with electronic cards used for payment.
Cancellations
Since we operate on an appointment only basis, your appointment time is reserved
exclusively for you. Please make every effort to be on time for your appointment. Please
notify our office at least 24 hours in advance if it is necessary to cancel or change a
scheduled appointment. Cancellations less than 24 hours in advance result in loss of
opportunity to help someone else who could have used that appointment time, and a financial
loss to the Provider.
A $50 fee will be assessed for session cancellations less than 24 hours in advance.
Thank you in advance for your consideration of appointment times.
Subpoena and Legal Documents Requests and Costs
Impact Counseling and Guidance Center seeks to safeguard your information and records, but
there may be times when disclosure of your records, testimony, or depositions will be
compelled by law.
Confidentiality and exceptions to confidentiality are discussed in the Policy, Procedures, and
Consent for Services document.
IT IS OUR POLICY TO NOT BE INVOLVED IN LEGAL ISSUES
REGARDING DIVORCE OR CHILD CUSTODY DISPUTES.
However, in the event disclosure of your records or the Provider’s testimony/deposition
are required by law concerning divorce or child custody disputes, you will be responsible
for all costs to Impact Counseling and Guidance Center for these
services, and shall pay the costs involved, including but not limited to,
postage/currier/communication services, legal fees, travel expenses, cost of producing necessary
records, and the Provider’s normal session rate per hour for the total number of hours it takes in
preparation for and in giving testimony or depositions.
When Impact Counseling and Guidance Center is advised of our involvement in legal
issues regarding divorce or child custody disputes, a $500 retainer for anticipated costs
concerning court/deposition appearances and/or legal preparation, etc. will be charged
to your card on file.
You will be supplied with an itemized invoice for all expenses applied to your retainer. If
the final costs incurred by Impact Counseling and Guidance Center are less than the
retainer, a refund will be sent within 10 business days. If costs are more than the retainer,
once the retainer fee is exhausted, your card will be charged additional expenses incurred by
Impact Counseling and Guidance Center for services rendered.
Typical Good Faith Estimated Costs Applied to Your Retainer:
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The typical cost for Impact Counseling and Guidance Center court/deposition appearances
is $115 per hour. This cost is billed per hour for each hour of time required for your
Provider to leave their residence or Impact Counseling and Guidance Center, appear at
court/deposition, and return to their residence or Impact Counseling and Guidance Center.
A typical cost estimate example for a Provider at Impact Counseling and Guidance
Center to be involved in a court/deposition appearance regarding divorce or a child custody
dispute would be:
Your Provider is required to appear in court at 1pm, is there until 5pm, and the travel time to
and from court is 1 hour each way.
Your estimated cost would be calculated from 12pm (time the Provider leaves for court)
to 6pm (the time your Provider returns from court) 6 hours X $115 per hour = $690
Typical cost for document reproduction is $.10 per page:
A typical estimated number of pages is 500 pages x $.10 per page = $50
Typical cost for Provider to make preparation for court/deposition appearance is 2
hours at a cost of $115 per hour.
A typical estimated cost of 2 hours x $115 per hour = $230
Typical Total Estimated Cost for Court/Deposition Appearance:
$690.00
$ 50.00
$230.00
$970.00 total cost
Typical costs of postage/courier/communication services vary, and we are not able to estimate
those costs. We will provide you with a copy of our invoice and you will only be billed the
amount we are charged.
Disclaimer
This No Surprise Act Good Faith Estimate Protection Document shows the costs of items and
services that are reasonably expected for services rendered by Impact Counseling and Guidance
Center. The estimate is based on information known at the time the estimate was created.
Good Faith Estimates do not include any unknown or unexpected costs that may arise when
services are being rendered. You could be charged more if complications or special
circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If billed for more than the Good Faith Estimates, you have the right to dispute the bill.
You may contact Impact Counseling and Guidance Center to let us know the billed charges are
higher than the Good Faith Estimates. You can ask Impact Counseling and Guidance Center to
update the bill to match the Good Faith Estimates, 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 initiate the dispute process. If the HHS agency reviewing your dispute
agrees with you, you will have to pay the price on this No Surprise Act Good Faith Estimate
Protection Document. If the HHS agency disagrees with you and agrees with Impact Counseling
and Guidance Center, 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 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 1-800-985-3059.
Notice of Privacy and Practices Document
Impact Counseling & Guidance Center
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Impact Counseling and Guidance Center (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.
UNDERSTANDING YOUR PRIVATE HEALTH INFORMATION: Each time you visit a hospital, physician, mental health professional or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, and treatment. In the case of a mental health professional, it contains psychotherapy notes and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
• Basis for planning your care and treatment.
• Means of communication among the many health professionals who contribute to your care.
• Legal document describing the care you received.
• Means by which you or a third-party payer can verify that services were provided.
• A source of information for public health officials charged with improving the health of the nation.
• A source of data for facility planning and marketing.
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
• A tool in educating health professionals.
Understanding what is in your record and how your health information is used helps you to:
• Ensure its accuracy.
• Better understand who, what, when, where, and why others may access your health information.
• Make more informed decisions when authorizing disclosure to others.
YOUR RIGHTS: Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.
To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice will charge a fee of $.10 per page. If you chose to not pick up paper copies in person, you will be charged an additional cost to send the records certified mail. If you authorize someone else to sign for and receive paper
documents in person or by mail, we must have a signed release from you on file, concerning the person you have authorized, prior to release of documents. For the release of electronic copies to anyone other than the client, a signed release must be on file, concerning the person authorized to receive the electronic transmission, prior to the release of documents.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.
To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice will require you to make your request in writing and provide a reason for the request. The Practice will act on your request within sixty (60) days, but this deadline may be extended for another thirty (30) days upon written notice to you.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.
To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.
To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• The Practice does not file insurance; therefore, you are paying the Practice in full for services rendered. If you choose to file for reimbursement with your health care provider, we will give you a diagnostic code to submit. You can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.
To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called Accounting, of the times your health information has been shared within the past 6 years. Disclosures that are exempted from the accounting requirement include the following:
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Disclosures that are necessary to carry out treatment, payment and health care options.
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Disclosures that are made to you upon request.
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Disclosures made pursuant to your authorization.
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Disclosures made for national security or intelligence purposes.
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Permitted disclosures to correctional institutions or law enforcement officials.
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Disclosures that are a part of a limited data set used for research, public health or health care operations.
We are required to act on your request for an Accounting within sixty (60) days but this deadline may be extended for another thirty (30) days upon written notice to you of the reason for the delay and the date by which we will provide the accounting. You can receive one accounting every 12 months at no charge, but you will be charged a fee of $.10 for each copied page if you ask for one more frequently.
To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.
Choosing someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
To file a complaint:
• Dr. Ed Laymance is the Director of Impact Counseling and Guidance Center and may be contacted regarding any complaints in writing or by phone at:
Impact Counseling and Guidance Center
2912 Little Road, Arlington, Texas 76016
817-457-6728
• In addition, you can file a complaint with Texas Behavioral Health Executive Counsel, 333 Guadalupe St., Ste. 3-900, Austin Texas, 78701. The phone number is 512-305-7700.
• The Practice will not retaliate against you for filing a complaint.
To opt out of receiving fundraising communications.
• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.
OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:
To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.
To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.
To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.
2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:
To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat to the health or safety of a person or the public and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.
To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request. This includes divorce and/or child custody cases and other legal proceedings in which your mental health or condition is in issue. NOTE: It is our policy to not be involved in legal issues regarding divorce or child custody disputes. However, in the event disclosure of your records or the Provider’s testimony/deposition are required by law, you will be responsible for all costs to Impact Counseling and Guidance Center for these services, and shall pay the costs involved, including but not limited to:
postage/currier fees/communication services, legal fees, travel expenses, cost of producing necessary records, and the Provider’s normal session rate per hour for the total number of hours it takes in preparation for and/or in giving testimony in court or depositions.
• Legal Disputes: to defend ourselves in a legal action or other proceeding brought by you against us. In addition, to file a suit for collection of fees for our services.
• Law enforcement: For law to locate and identify you or disclose information about a victim of a crime or if we believe in good faith that the PHI constitutes evidence of criminal conduct that occurs on our premises.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.
To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.
3. Uses and Disclosures of PHI That May Be Made with Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI: To your family, friends, or others if PHI directly relates to that person's involvement in your care or if it is in your best interest because you are unable to state your preference.
4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes: Marketing, sale of PHI, and psychotherapy notes.
You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.
OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above.
• The Practice will inform you if PHI is compromised in a breach.
If you have any questions or concerns regarding your PHI, you may contact Tonya Trentham, our Privacy Officer, at (817) 457-6728. If you need to file a complaint regarding your privacy rights, you may contact the Department of Health and Human Services at 1-866-627-7748.
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