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.

Confidentiality

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.
You have the right to know the professional education and qualifications of the staff member(s) providing services.

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.).

Acknowledgments

Outside Office Setting Acknowledgement*

I understand when services are provided outside of the office setting what is discussed between me, my family, the 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.

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 the information. I agree that all my questions, if any, have been answered related to my rights and responsibilities.

Person receiving services*

First Last

Person receiving services signature*

Date of birth*

Parent/Legal Guardian signature (if needed)

Today's date*