Statement of custody, application for service and service agreement

I understand that:

1. Services may include individual therapy, family therapy, group therapy, psychiatric evaluation, outpatient medical services, school-based medical services, comprehensive crisis assessment and/or psychiatric medication management
2. For behavioral health and psychiatric services, Child and Family Agency of Southeastern CT, Inc. (CFA) does not dispense medication.
3. CFA staff are mandated reporters. In the event of suspicion of abuse or neglect, staff will seek supervisory input and may need to file a report with child protective services or seek emergency response for the safety of my child or others.
4. The Agency’s administration offices are operational Monday through Friday, between the hours of 8:30 am and 4:30 pm. Clinical services hours vary by program as stated on forms.childandfamilyagency.org. In case of urgent/emergent concerns after office hours, the Agency provides 24/7 on call support to current clients. The crisis clinician can be reached by calling 860-440-7182. For life-threatening emergencies, families should call 911 immediately.
5. If emergency medical treatment is necessary for any client under the age of 18, Agency staff will seek Parent(s)/Guardian(s) assistance and/or call 911.
6. For individuals under 18, a responsible adult may be required to be available during the duration of the appointment.
7. Parents/Guardians with clients under the age of 12 must be available for the duration of the appointment. It has been explained to me that a person receiving services who is under 18 becomes uncomfortable during a session they may stop the session at anytime and access their parent/guardian. All parents/guardians may be asked to remain a part of session with when deemed clinically necessary by the provider.
8. For in-home services, a parent, legal guardian, or a resident over the age of 18 years of age must be present.
9. For the Urgent Crisis Center, a parent or legal guardian must accompany all minors under the age of 18 years of age.

CLIENT RIGHTS AND RESPONSIBILITIES

Person(s) receiving services from Child and Family Agency of Southeastern Connecticut, Inc., (CFA) or its affiliates, are entitled to certain rights and responsibilities.

• No information about you or your treatment will be shared with anyone outside of the Agency without your permission. To provide the best coordinated care, CFA staff may share information between Agency programs. If more than one adult name is in a case record, all adults would need to give permission for that information to be shared.
• The Agency’s focus is on the client’s mental health and well-being; therefore, we do not get involved in custody disputes or provide written recommendations relating to custody.
• If the Agency receives a Subpoena from the court, the Agency must follow state law. Staff do not appear in court unless subpoenaed to do so. If subpoenaed, the Agency may charge a minimum of $1500.00 (for the first three hours) per staff member for each court appearance.
• CFA strives to create and refine more effective ways to help children and families across services. For this reason, we carefully evaluate the effectiveness of our programs and use de-identified information for internal agency reporting and statistical purposes, and for satisfying the data submission requirements of our funding sources. Beyond such requirements, any use of identifying Protected Health Information for external research purposes will only occur with your written authorization or through approval from an Institutional Review Board or Privacy Board established in accord with Federal law.

Client Rights

• You have the right to equal treatment without regard to race, color, spiritual beliefs, sex, gender identity, sexual orientation, and/or national origin.
• You have the right to services that take into consideration your culture and your spoken language.
• You have the right to be actively involved in treatment planning, and ongoing decisions, including type of service.
• You have the right to review the case chart within the limits of confidentiality. This is done in the presence of the provider and/or supervisor. Clients also have the right to insert statements into the case record. CFA is responsible for deciding whether the review or release of information would be potentially harmful to a minor child.
• You have the right to request a change in staff assignment following the Agency’s grievance procedure.
• You have the right to refuse services at any time. The client should discuss ending services with their assigned staff member.
• You have the right to seek another opinion from an individual or organization outside of CFA regarding diagnosis, medications, or treatment planning.
• You have the right to be informed of and to refuse any audio/audiovisual taping.
• You have the right to be informed of any possible risks and benefits associated with the treatment or service plan. You have the right to a full discussion of treatment alternatives.
• The client may, at any time, request information regarding the professional education and experience of the treating clinician.

Client Responsibilities

Safe and Respectful Treatment Environment

You are responsible for helping the Agency maintain a safe and respectful treatment environment. Adults and children are expected to act safely and appropriately towards all staff, family members, and other clients. This includes, but is not limited to:

• While receiving services, rude or obscene language, evidence of intoxication or substance use, and/or verbal/physical threats will not be tolerated and may result in termination of services.
• Threats or actions against oneself or others are not protected by confidentiality and may be reported to the appropriate authority.
• Weapons are prohibited on our premises. If receiving services at home, weapons need to be disclosed, locked and secured.
• You are responsible for providing the supervision of any children in your care.

Financial Responsibilities

You are responsible for providing all the financial information necessary for the Agency to provide services, including insurance coverage.

• You are responsible for payment at the time of service, when indicated. If you transition from one Agency program to another, payment for a previous outstanding balance is expected. Withdrawing from a program with an outstanding balance may also jeopardize future involvement with Agency programs.
• You are responsible for informing your provider about other services you are currently receiving that could be a duplication of services.
• You are responsible to promptly provide any changes in information that relates to treatment, billing and contact (e.g., name, address, telephone number, insurance, employment, family composition.).

Notice of Privacy Practices

PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND ACCESSED BY YOU.

Click here to review the Agency’s Privacy Practices

Click here to review the Agency’s Privacy Practices Acknowledgement

Release of Health Information and Assignment of Benefits

The following form requests information about your insurance. Please have your insurance information ready to fill out this form.

FINANCIAL RESPONSIBILITY AGREEMENT

Please read carefully and agree to the following:

Financial Responsibilities

• I agree to submit accurate financial information as requested, i.e. third-party coverage, Husky (Medicaid), Medicare, and household’s gross weekly income minus taxes. I agree to provide the CFA with other documentation of income as necessary.
• I agree to provide CFA with a Husky or commercial insurance card upon the first visit.
• I agree to provide CFA with a signed major medical insurance form authorizing payment directly to the agency no later than the second visit and understand that I am responsible for any payment not met.
• I agree to pay the client fee at each visit, and if I miss one payment, I will remit payment at the next therapy session along with that session’s fee. If two payments are missed in a row, I understand the client may be asked to reschedule any future appointment until payment is received. I understand if the client’s account has three or more payments in arrears, service may be suspended until such time as the client’s account is paid in full. If you are in a financial crisis, payment options are available, and our Billing Department is willing to work with you to resolve payment balances.
• I agree to notify CFA promptly of any change in my or the client’s financial or insurance status which may/may not affect the fee.
• I understand that CFA has the right to request an update of my or the client’s financial income information and to request validation of hardship before the client fee is reduced.
• School-based health center services do not charge out-of-pocket fees, including co-pays or deductibles.
• I agree to pay the client responsibility after insurance makes payment on services. I understand this amount is subject to change based on deductible, copayment and/or coinsurance.
• We understand the financial hardship for many of our clients and, as such, have developed alternative payment systems for those clients.
• I understand I can contact the billing department and the client’s clinician for questions and payment options. The billing department can be reached at (860) 437-4550.

For child outpatient services and in-home services

• If the client is privately insured under a high deductible plan, then there will be a charge of $150.00 upon Intake and approximately $120 per session thereafter until the deductible has been met. Once deductible is met, a co-pay will be assessed based on the client’s insurance plan.
• If the client has Tri-Care and is assigned to an unlicensed clinician, there will be no charge to the client. If your case is reassigned to a licensed clinician an appropriate copay will be established at that time.
• We offer a sliding scale fee based on the total household income and the number of household members. This information can be provided at intake/registration or upon request to a Client Support Specialist.
• CFA offers fee reductions for those who are unable to pay the full fee at each session, their established co-pay or sliding scale fee. Should you need a fee adjustment, please request from the Client Support Specialist.

School-Based Health Center

• School-Based Health Center services do not charge out-of-pocket fees, including co-pays or deductibles. However, we do bill your or the client’s insurance(s) and therefore it is crucial that we have all of this information upon first visit.

Adult Outpatient Treatment Program

• Adult Outpatient Treatment Program (AOT) is unable to adjust fees; the full cost agreed to at intake must be paid for each session.
• The AOT fee for Intake is $150 and subsequent therapy sessions are $120.

CONSENT AND NOTICE REGARDING ELECTRONIC SIGNATURES

Electronic Signature Agreement

I give consent for myself and/or any minor child in my custody for Child and Family Agency of Southeastern Connecticut, Inc. (CFA) to collect an electronic signature on documents including but not limited to treatment such as assessments, treatment plans, and treatment plan updates. By signing below, I agree that my electronic signature is the equivalent of my manual signature. I further agree that the use of a keyboard and mouse to select an item and to collect the electronic signature constitutes my signature, acceptance and agreement as if actually signed by myself in writing. I further agree that each use of my e-signature in signing documentation constitutes my agreement to be bound by the terms and conditions of the Electronic Signature Agreement as it exists on the date of my e-signature.

Revocation of Electronic Signature

I understand that I have the right to withdraw my consent to electronically sign documents. Withdrawing consent can be completed by speaking with CFA staff in-person or by phone.

CONSENT TO TELEHEALTH AND ELECTRONIC COMMUNICATION AGREEMENT

CONSENT TO TELEHEALTH

Telehealth allows Child and Family Agency of Southeastern CT, Inc. (CFA) providers to diagnose/evaluate, consult, treat, educate, and manage care using interactive audio, video or data communication. I hereby consent to participating in psychotherapy, psychiatric evaluation, including medication management for psychotropic medications, and medical services via telephone or the internet (hereinafter referred to as Telehealth) with my CFA providers.

I understand I have the following rights under this agreement:

1. I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person appointments. Any information disclosed by me during the course of my treatment, therefore, is 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 sharing of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my informed consent.
• I agree not to record and/or distribute my telehealth therapy sessions.
2. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our telehealth appointments could be disrupted or distorted by technical failures or could be interrupted.
3. You or your CFA provider(s) may determine that a higher level of care than Telehealth is required to meet your unique treatment needs, at which time a referral will be made to the appropriate provider.
4. You are responsible for payment at the time of service, including for telehealth appointments.

I have read and understand the information provided above. I have the right to discuss any of this information with my clinician 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 at any time verbally and in writing.