Healthy Futures Intake

Step 1 of 6 – Healthy Futures Intake

Office of Early Childhood (OEC) & Child and Family Agency of Southeastern CT, Inc. (CFA) Healthy Futures Program Consent for Home Visiting and Participation Family Rights, Responsibilities and Confidentiality Policy

Program Description
Healthy Futures is a home visiting program for families and children, prenatal through 5 years of age serving Middlesex County. Healthy Futures follows the Parents as Teachers (PAT) curriculum, an evidenced based model to promote optimal early development, learning and health of children by supporting and engaging parents and caregivers. Healthy Futures provides personal visits in the home to facilitate parent-child interaction, group connections to support family interaction and provide a community support network, child screenings to monitor child development and resource connections to assist families in accessing resources to meet their needs. Healthy Futures works in collaboration with Connecticut Doulas to provide physical and emotional services for expectant families during pregnancy, childbirth and the postpartum period. The Office of Early Childhood home visiting program is free of charge to families. It is the parents’ choice to receive home visiting services. The home visiting program offers parent education, support and information on community services.

Family Rights and Responsibilities
The program staff know that the decisions families make are important to the lives of their children. Your feedback and participation are important to the Healthy Futures Program. Knowing your rights about being part of this program is also important. To protect your rights, the home visiting program would like you to know that:

1. You have the right to choose yes to receive home visiting services, which includes planning activities around your needs.

2. You have the right to choose no and refuse home visiting, or end home visiting services at any time.

3. You have the right to transfer to another home visiting program. Your current program will help you make the change.

4. You have the right to your privacy. Your information and records will remain confidential in both electronic and hard copy.

5. You have the right for your electronic information to be password protected. Your name will not be directly identified in that form (de-identified).

6. You have the right to your privacy, any information that is shared publicly will not include your name, your child’s name, your address or any other personal information, (aggregate form).

7. You have the right to look at your home visiting record.

8. You have the right to ask for a copy of your personal home visiting record.

9. You have the right to report any issues with the home visiting program to the home visiting program manager, Erin Tascher (860-910-9890 or [email protected]) or the Office of Early Childhood. All complaints will be carefully reviewed.

10. If you agree to home visiting services, your name may be connected with receiving OEC home visiting services. This information may be available to others, including staff at the OEC and other state agencies, and additional home visiting programs. No additional information other than your participation in the program will be shared.

Child and Family Agency of Southeastern CT, Inc. (CFA) Healthy Futures Program Court Policy

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. The only exception to this policy is the Reunification and Therapeutic Family Time (RTFT), as this program does make recommendations to DCF for placements in their Readiness Assessment component.

If the Agency receives a Subpoena from the court, the Agency must follow state law. Staff does 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.

My signature below indicates that I have read the Healthy Futures Program Consent for Home Visiting and Participation Family Rights, Responsibilities and Confidentiality Policy and the Healthy Futures Program Court Policy.

Office of Early Childhood (OEC) & Child and Family Agency of Southeastern CT, Inc. (CFA) Healthy Futures Home Visiting Program Consent for Home Visiting Program Participation Family Rights, Responsibilities and Confidentiality Policy
I understand that suspected abuse or neglect will be reported.

Participation Acknowledgement(Required)

Yes, I would like to participate in the Healthy Futures program for parent education, support and information on community services. I understand my rights and responsibilities that were listed in this form. I understand that the home visiting program will contact me to schedule the first home visit.

No, I do not wish to receive home visiting services, but I give permission to enter very little demographic information and risk information into the home visiting database.

Date(Required)

Client Signature(Required)

Guardian Signature

For caregivers who are transferring from one home visiting program to another, or who are re-enrolling in home visiting:

Yes, I would like to continue my participation in the home visiting program. I understand my rights and responsibilities that were listed in this form. I understand that my previous electronic home visiting record will be made available to my current home visitor. I understand that the home visiting program will contact me to schedule the first home visit.

Date(Required)

Client signature(Required)

Guardian Signature

Authorization for Health Information Exchange (HIE)

The HIE system is a secure computer system that brings your protected health information from different healthcare locations into one nationwide electronic health record.

The HIE system network provides participating practitioners access to past and present medical and behavioral health information to make better decisions and better coordinate care across your care teams.

The HIE system takes your privacy and security very seriously. The HIE system does not store any of your health/clinical data and uses end-to-end encryption to help ensure your data is secure when sending data. Only those involved in your care can look at your information.

Client's Name(Required)

First Last

Date of Birth(Required)

The State of Connecticut participates in the Health Information Exchange, meaning that medical health information (e.g. immunizations, medications, physical examinations, etc.) are shared with other medical providers unless a specific opt-out is received.

Do you want to opt-out of any medical information being sent to other health care providers?(Required)

Yes

Additionally, sensitive PHI is PHI that is “subject to heightened confidentiality requirements in compliance with all federal and state laws as amended from time-to-time (e.g. HIV, substance abuse and mental health records).”

Patients must specifically authorize disclosures of sensitive PHI.

Do you want to opt-out of sensitive PHI (e.g. HIV, substance abuse, and mental health records) being sent to other providers?(Required)

Yes

By signing below, I understand and acknowledge the following:

My sensitive health information will be available to providers using The HIE system.
I understand that refusal to sign this authorization form will not affect my right to obtain present and future services. I also understand that I may opt-out of HIE by notifying Child and Family Agency of the named recipient in writing.

Electronic signature of person authorizing health information exchange(Required)

Relationship to Patient (If <18 years of age):

Today's Date(Required)

Healthy Futures Intake

Healthy Futures

Adult Information

Child Information

Employment and Referral Information

Participant Consent

AUTHORIZATION FOR THE RELEASE OF INFORMATION

INFORMED CONSENT TO TELEHEALTH

Notice of Privacy Practices

Authorization for Health Information Exchange (HIE)