Consent for Treatment and Service Agreement

o Services are individualized based on the client’s needs, clinical or medical
assessment, and program eligibility.
o Services may include individual therapy, family therapy, group therapy, psychiatric
evaluation, outpatient medical services, school-based medical services, psychiatric
medication management, and/or non-clinical community programs.
o Services may be provided in person, through telehealth, in the community, in schools,
or in the home depending on program availability and clinical need.
o When telehealth services are provided, the client must be physically located in the
state of Connecticut.

o I understand that confidentiality and privacy practices are explained in CFA’s Client
Rights and Responsibilities and Notice of Privacy Practices documents.
o When services are provided outside of a CFA office, conversations may be overheard
by individuals who are not participating in treatment. While CFA will make
reasonable efforts to protect privacy, complete confidentiality cannot be guaranteed in
these settings.

o CFA staff are mandated reporters. In the event of suspected abuse or neglect, staff
will seek supervisory input and may be required to file a report with child protective
services or seek emergency intervention to ensure the safety of the client or others.

o CFA administrative offices are open Monday through Friday, 8:30 a.m. to 4:30 p.m.
Clinical service hours vary by program. Current clients have access to 24/7 on-call
support for urgent concerns by calling (860)440-7182. In a life-threatening
emergency, call 911.
o If emergency medical treatment is necessary for a client under the age of 18, CFA
staff will attempt to contact the parent/legal guardian and may call 911 when
necessary to protect the health and safety of the client or others.

o Clients are expected to attend scheduled appointments and participate in treatment in
accordance with the Client Rights and Responsibilities Agreement.
Please refer to that agreement for the full description of client responsibilities and expectations
related to participation in treatment.
o For clients under 18, parents/legal guardians may be required to be available during
the duration of the appointment or asked to participate in treatment sessions when
deemed clinically necessary by the provider.
o For clients under 12 years of age, a Parent/Legal Guardian is required to remain
available for the duration of the appointment to provide support and assistance as
needed. This requirement does not apply to appointments held at SBHCs.
o If a client becomes uncomfortable during a session they may stop the session at any
time, and if under the age of 18 may access their parent/legal guardian.

o Do not replace the client’s regular community primary care provider. If a client does
not have a primary care provider, staff will assist them with a referral to a primary
care medical home.
o If opting in I consent that the client specified can obtain routine health services at a
CFA SBHC, including annual recommended screenings and preventative visits.
o I authorize CFA to exchange information as needed with the client’s primary care
provider, school nurse, and key school district personnel to effectively care for the
client. I understand that the SBHC medical and behavioral health providers may
communicate with one another about client care.
o I understand that my child will continue to be enrolled in a CFA SBHC if child is
enrolled in a school that has a CFA SBHC, although yearly updates will be requested.
o I recognize that health records, if received by the school district, may not be protected
by the HIPAA Privacy Rule, but will be education records protected by the Family
Education Rights and Privacy Act.

o For in-home services, a parent/legal guardian or another responsible adult (18 years
of age or older) who resides in the home must be present.
o For in-home services, clients shall to the best of their abilities provide a safe
environment for sessions to be completed, in alignment with CFA’s Client Rights and
Responsibilities.
o For the Urgent Crisis Center, a parent/legal guardian must accompany all minors
under 18 years of age.