Psychiatric Medication Management Responsibilities

By acknowledging the statements below, you agree to the following:

Prescription Acknowledgement*

For new medication requests, we will not handle over the phone or electronically; these requests need to be made in-person during an appointment.

Medication Management*

If you or your dependent receive medication management through Child & Family Agency of Southeastern CT, Inc. (CFA), you are responsible to give your psychiatric provider seven days advance notice for medication refills. The Agency is not responsible for providing refills if less than seven days’ notice is given. Please contact your pharmacy or emergency department if an emergent script within 7 days is needed.

Paperwork Request Acknowledgement*

I acknowledge that paperwork left for the prescriber outside of scheduled appointments cannot be addressed on an urgent basis and will be attended to only as the doctor’s availability allows. CFA will do their best to get your records in a timely manner, but per State of Connecticut regulations, this may take up to thirty days.

Outside Office Setting Acknowledgement*

I understand when services are provided outside of the office setting what is discussed between me, my family, CFA staff, and other parties indicated on my treatment plan may be heard by other parties present. Even though these parties may hear confidential information discussed, I consent to allowing the meetings to be held.

Medication Appointments for Psychiatry*

The client and guardian(s) (if applicable) must attend all scheduled medication appointments as issues relevant to the client’s medication will be addressed at this time. This includes prescription refills and any necessary medical forms for school, camp, etc. This requires the client and guardian(s) to plan ahead regarding concerns, forms, and prescription needs. If the client has taken medication as directed and attended scheduled medication follow-ups, then they should not run out of medication in between appointments.

Medication Safety*

Medications must only be taken as prescribed. The client and/or guardian have a responsibility to notify their prescriber of any side effects, significant changes in mood noticed, safety concerns the use of alcohol or recreational drugs, new medical issues, or any other prescribed or over-the-counter medications the client is taking.

Medication Issues*

It is expected that medication issues will be addressed during appointments. If changes arise that require psychiatric care prior to the client’s next appointment, call the central line at (860)437-4550 to schedule a visit.

Releases of Information*

Client and/or guardian receiving psychiatric medication only services through CFA are responsible for providing releases of information to external treatment providers for coordination of care including counseling, primary care, or other applicable service providers.

Rights and Responsibilities Acknowledgement*

I have received, read and reviewed my rights and responsibilities with a CFA staff member and fully understand and agree to them. I hereby request services for myself/child/family. I agree that I have read and understood this acknowledgment. I agree that all my questions have been answered related to my rights and responsibilities.

Person Receiving Services Legal Name*

First Last

Person Receiving Services Signature*

Today's date*

Date of Birth*

Parent/Legal Guardian Signature (if applicable)

Today's date*