Early Childhood Mental Health Consulting 

I understand that:

1. Services will include what is discussed and agreed upon between the clinician and the family member.
2. CFA does not dispense medication.
3. Mental health 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. CFA ECMHC are operational Monday through Friday, between the hours of 8:00 am and 4:00 pm, with additional ‘after school’ hours provided as needed and if available. In case of urgent/emergent concerns after office hours, you are welcome to leave a voice message for your community worker and/or clinician. They will return your call promptly at the start of the next business day. For life threatening emergencies, families should call 911 immediately.
5. If 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. Parents/Guardians engagement in services is pertinent to the child’s success.
7. Parents/Guardians have the right to discontinue services/supports at any time.
8. The clinician and/or community worker providing services will coordinate with school personnel on an as needed basis to best support the needs of the child and family (release of PHI will be required to be signed by parent/guardian)

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 supportive services 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.
• The Agency’s focus is on the child/family’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.

ATTENDANCE POLICY

• Cancellations/Missed Appointments: A pattern of missed appointments may lead to your appointment time not being guaranteed in the future.
• If you or your child are sick and cannot attend the appointment, contact your community worker as soon as possible to reschedule. Staff will make every effort to shift your appointment to telehealth (if appropriate) and/or reschedule as soon as possible.
• If you are unable to attend your appointment, you must cancel your appointment 2 hours prior to the appointment time.
• If you cancel late (meaning less than 2 business days’ notice) and are unable to reschedule your appointment within the same week (or Friday appointments to the following Monday), your appointment will be coded as a “No-Show” appointment.
• If you are more than 15 minutes late for your appointment, your appointment will be canceled and considered a “No-show” appointment.
• Three cancellations in a 2 month period will result in a discussion with your community worker to determine if this is the appropriate time to be engaging in services and/or to identify and overcome barriers that prevent consistent attendance.
• Two “No-Show” appointments in a row, without any contact, can result in a discontinuation of services.

GRIEVANCE PROCEDURES

Click here to review the Grievance Procedures online. 

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

By signing below, I understand and acknowledge I have read and understand: 

CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES 

I understand and acknowledge that I have read and understand this consent and I have received CFA’s Notice of Privacy Practices   currently in effect. I understand that information regarding how CFA will use and disclose my information can be found in CFA’s Notice of Privacy Practices  I understand my consent is effective for as long as CFA maintains my protected health information. 

Printing and signing your name below acknowledges that you have reviewed the information above and consent for services.