All information on this registration must be dated and signed before your child can receive services from the School Based Health Centers (SBHC) at Child and Family Agency of Southeastern Connecticut, Inc. (CFA). If a student is 18 or older, they may sign their own permission form. Race & ethnicity information is required by the State and will be used for statistical purposes only.

STUDENT INFORMATION

Full legal name (of person who will receive services)*

First Last

Date of Birth*

Student Grade*

School that Person Receiving Services Attends (check box next to school):*

Students enrolled at Stonington Middle School, Dean’s Mill Elementary School, and Charles Barnum Elementary School are eligible for SBHC Medical services only. Medical appointments will be scheduled at a SBHC within district whenever possible. Mental Health services are NOT available at those sites. To receive information about receiving mental health services at one of CFA’s four Outpatient Clinics, please call 860-437-4550.

Address*

Street Address Address Line 2 City State ZIP Code

Assigned Sex*

Male

Female

Other

Ethnicity*

Hispanic

Non-Hispanic

Gender Identity

Male

Female

Transgender Male

Transgender Female

Non-binary

Other/Prefer not to Answer

Language Spoken at home:*

Race*

Unknown

American Indian

Pacific Islander

Alaskan Native

Black

Asian

White

Other

AGREEMENT TO RECEIVE SERVICES*

I am the legal guardian of a minor, who is receiving services. I have the authority to make decisions about treatment.

I am receiving services and I am over 18. I hereby agree to engage and participate in treatment.

SELF/PARENT/LEGAL GUARDIAN INFORMATION

Name*

First Last

Relationship to Student*

Parent

Legal guardian

Define*

Address (If different from above)

Street Address Address Line 2 City State ZIP Code

Secondary Emergency Contact

First Last

Emergency Contact Phone

ACKNOWLEDGEMENT AND CONSENT

School-Based Health Center (SBHC) Program

ACKNOWLEDGEMENT AND CONSENT

By signing below, I understand and acknowledge I have read and understand this consent- I give permission for my child/self (>18 years old) to obtain routine health services at the School-Based Health Center. The SBHC does not replace your regular community primary care provider. If you do not have a primary care provider, the SBHC will assist you in a referral to a primary care medical home.

Grievance Procedure

https://forms.childandfamilyagency.org/wp-content/uploads/2023/06/GRIEVANCE-PROCEDURE-final-6.1.2023-1.pdf

Grievance Procedure Acknowledgement*

I acknowledge reading the Agency’s Client Grievance Procedures

Client Rights and Responsibilities

https://forms.childandfamilyagency.org/wp-content/uploads/2023/11/04-Clients-Rights-and-Responsibilities-5-2.pdf

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.

Privacy Practices

https://forms.childandfamilyagency.org/wp-content/uploads/2024/07/05-Notice-of-Privacy-Practices.pdf

Consent and Acknowledgement of Privacy Practices*

I 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.

Financial Responsibility Agreement

https://forms.childandfamilyagency.org/wp-content/uploads/2025/03/Financial-Agreement.pdf

Financial Responsibility Acknowledgement*

I have received, read, and understand the agency’s Financial Responsibility Agreement. I understand and acknowledge School-Based Health Center services do not charge out-of-pocket fees, including co-pays or deductibles. However, we do bill your or the client’s insurance(s) and therefore it is crucial that we have all this information upon first visit.

AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION BY SBHC

I give permission to allow Child and Family Agency to exchange as needed information with the client’s primary care provider, school nurse, and key school personnel to effectively care for my child. I understand that the SBHC medical and behavioral health providers may communicate with one another about the client’s care.

I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the client’s health. I will notify the SBHC of any changes.

Age appropriate, annual risk assessment screenings are completed with students enrolled in the SBHC as part of best-practices in pediatric care. Please reach out to the Medical Services program at (860) 437-4550 option 3 or your SBHC provider with any questions or concerns.

Signature of Parent/Legal Guardian/Personal Representative (or Student if over 18 years old)*

Print Name

First Last

Date*

By signing above, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I understand that my child will continue to be enrolled in a CFA SBHC as long as child is enrolled in school that has a CFA SBHC, although yearly updates will be requested. I recognize that health records, if received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by the Family Education Rights and Privacy Act.

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.

Student's Name*

First Last

Student's Date of Birth*

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.

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.*

I opt-in for CFA to share information from and to the HIE.

I want to opt-out of any medical information and sensitive PHI being sent to other health care providers.

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 Southeastern CT, Inc. of the named recipient in writing.

Electronic signature of person authorizing health information exchange*

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

Today's Date*

Forms – SBHC Registration

STUDENT INFORMATION

STUDENT’S PRIMARY CARE PROVIDER

MEDICAL HISTORY

SELF/PARENT/LEGAL GUARDIAN INFORMATION

COMMUNICATION AGREEMENT

INSURANCE INFORMATION

ACKNOWLEDGEMENT AND CONSENT

School-Based Health Center (SBHC) Program

ACKNOWLEDGEMENT AND CONSENT

Grievance Procedure

Grievance Procedure Acknowledgement*

Client Rights and Responsibilities

Rights and Responsibilities Acknowledgement*

Privacy Practices

Consent and Acknowledgement of Privacy Practices*

Financial Responsibility Agreement

Financial Responsibility Acknowledgement*

AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION BY SBHC

Authorization for Health Information Exchange (HIE)