Cathy Jordan MA, LPC,

3920 Cypress Creek Pkwy. FM 1960 Suite 250

Houston, Texas 77068

Greetings,

Our office is aware of the recent pandemic that has affected many individuals worldwide. We want to assure you that we are taking the necessary precautions to keep our clients safe to the best of our ability. Although we are uncertain of what the future holds, our office guarantees that there will be no interruption in services that we provide.

Should there be a reason for our office to close, we are prepared and excited to offer teleconferencing. Please take a moment to go over our Teleconference Protocols that we have attached. Should you have any questions please call our office Monday-Thursday 12a-7p.

As you probably are aware, Harris and surrounding counties have declared a disaster relating to COVID-19, and President Trump just declared a National Emergency.

We are now offering teletherapy sessions in case you are unable to come to the office. In the event of a total quarantine by our President or Harris County elected staff, we will utilize teletherapy as our way of completing services.

During the COVID crisis, all insurance companies have approved teletherapy.

Normally your insurance company would have to approve teletherapy for it to be utilized. For those who are willing to try video sessions with me, I think you will be pleasantly surprised at how effective and convenient they can I will be using the video service offered through my HIPAA compliant practice management provider( Doxy.me). if Doxy.me has technical difficulties, we may use another platform and you will be notified. Copy and paste or click my link in your browser to begin your appointment. https://doxy.me/jordanlpc . It can be accessed through desktop computer and mobile device. (Android or IOS). I am attaching a “getting started” video guide from Doxy to show how it works.

https://www.youtube.com/watch?v=CmlNbWgUeJc

For clients who do not wish to do video sessions, I will also still offer telephonic sessions; simply let me know your preference.

1. Please call the office to schedule an appointment if you do not have a follow up appointment; you will still receive appointment reminders from our automated system via text.
2. Our office will ensure that your insurance is verified and active. New patients need to provide insurance information 48 hours prior to the visit. We will need the member number, group number, birthdate, place of employment, address and if your deductible applies. There should also be a customer or service provider number so that we may verify your benefits. If you have an EAP benefit, we need your EAP authorization number, (beginning and ending date) and the number of sessions approved.

3.Teleconference options: Via telephone

-The provider will call you at the time of your appointment.

- Please be sure you have access to a quiet area for 45 minutes Via Video Conference

-Your session will be conducted via video chat at Doxy.me

-You will receive an additional appointment invitation from Doxy.me as well as a link to sign in for your appointment.

-Please log in 5 minutes before your appointment.

-Please be sure you have access to a quiet area for 45 minutes.

. We will continue to collect co-pays through PayPal.

4. While you are making/setting your appointment, please be sure to specify your teleconference preference (Telephone or video chat).
5. Should you need to cancel your appointment for any reason, please do so 48 hours before your appointment. Failing to cancel within the 24-hour window or canceling the same day of your appointment will result in a $75 cancellation fee.
6. If you experience any flu like symptoms, cough, fever, please call to reschedule. You will not be charged a cancellation fee if you are ill.
7. Please call 911 for all emergencies or go to your nearest emergency room.
8. Paperwork can be sent to [email protected]
9. Parents or guardians please be available to your child’s teletherapy sessions. Please gather some of your child’s toys for the session. Puppet, stuffed animal, doll, coloring paper and crayons, writing paper, small toys, sand tray, slime or play dough and books.

Sincerely, Cathy Jordan MA LPC-

CLEAR CHANNEL COUNSELING INFORMED CONSENT TO TELE-HEALTH

Telehealth allows my therapist to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. I hereby consent to participating in psychotherapy/coaching/parenting training via telephone or the internet (hereinafter referred to as Telehealth) with the clinician listed below:

Client Name: _________________________________________________________________

Clinician: ________Cathy Jordan MA LPC, ______________________________________

I understand I have the following rights under this agreement:

I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential.

There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent.

I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. In addition, I understand that Telehealth treatment is different from in-person therapy and that if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.

I have read and understand the information provided above. I have the right to discuss any of this information with my therapist and to have any questions I may have regarding my treatment answered to my satisfaction.

I understand that I can withdraw my consent to Telehealth communications by providing written notification to Prepare to Change. My signature below indicates that I have read this Agreement and agree to its terms.

Signature:____________________________________________ ________________________

The Privacy Rule and Public Health- COVID 19 EXCEPTIONS

The Privacy Rule recognizes 1) the legitimate need for public health authorities and others

responsible for ensuring the public's health and safety to have access to PHI to conduct their

missions; and 2) the importance of public health reporting by covered entities to identify threats

to the public and individuals. Accordingly, the rule 1) permits PHI disclosures without a written

patient authorization for specified public health purposes to public health authorities legally

authorized to collect and receive the information for such purposes, and 2) permits disclosures

that are required by state and local public health or other laws.