Billable Intake - English (rev 20221118) "*" indicates required fields Step 1 of 9 - Statement of custody, application for service, and service agreement 11% Child and Family Agency Intake Form Statement of custody, application for service and service agreementClient name* First Last Address* Street Address Address Line 2 City ConnecticutAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If client is under 18 years oldAgreement to receive services* (client under 18 years old) I hereby state that I am the legal guardian of the following child, and I have the authority to make decisions about treatment services. Client date of birth* MM slash DD slash YYYY Client relationship to legal guardian* Client 18+ years oldAgreement to receive services* (client 18+ years old) I hereby agree to engage and participate in Child and Family Agency services. Terms of Service AgreementI understand that: Services may include individual therapy, family therapy, group therapy, psychiatric evaluation and medication management. Child and Family Agency does not dispense medication. 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. The Agency is operational Monday through Friday, between the hours of 9:00 am and 5:00 pm, with additional hours varying by program. In case of urgent/emergent concerns after office hours, the agency provides 24/7 on call support to current clients. The on-call clinician can be reached by calling 860-823-0893. For life threatening emergencies, families should call 911 immediately. 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. Parents/Guardians with clients under the age of 12 must be available for the duration of the appointment. It has been explained to me and the minor client that if he/she becomes uncomfortable during a session he/she may stop the session at anytime and access his/her parent/guardian. All parents/guardians may be asked to remain a part of session with the client when deemed appropriate by the therapist. Agency Client Grievance Procedures*Click here to review the Grievance Procedures online. I acknowledge reading the Agency's Client Grievance Procedures Agency Attendance Policy*Click here to review the Agency Attendance Policy I have reviewed and will comply with the Agency’s Attendance Policy Client signature* Date of Client signature* MM slash DD slash YYYY Legal guardian signature* Legal guardian relationship to client* Date of Legal guardian signature* MM slash DD slash YYYY Parent/guardian signature (client 2) Date of parent/guardian signature (client 2) MM slash DD slash YYYY Legal guardian (2) signature Legal guardian (2) relationship to client Date of Legal guardian (2) signature MM slash DD slash YYYY Client rights and responsibilities Psychiatric medication management Persons receiving service from Child and Family Agency of Southeastern Connecticut, Inc. or its affiliates are entitled to certain rights and have certain responsibilities. Client Rights Confidentiality No information about you or your treatment will be shared with anyone outside of the Agency without your permission. In order 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. 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. Services You have the right to equal treatment without regard to race, color, spiritual beliefs, sex, sexual orientation, 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 therapist and/or supervisor. Clients also have the right to insert statements into the case record. Child and Family Agency is responsible for deciding whether the review or release of particular 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 seek another opinion from an individual or organization outside of the Agency regarding diagnosis, medications, or treatment planning. You have the right to be informed of and 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 of the staff member(s) providing services. Prescription acknowledgement* I acknowledge that prescription requests will NOT be managed over the phone or called in to the pharmacy. Prescription refill requests will not be handled outside of prescriber’s normal business hours. Clients may be offered a follow-up clinic visit with an alternative medical provider for bridge scripts as needed based on staff availability. Paperwork acknowledgement* I acknowledge that paperwork left for the doctor outside of scheduled appointments cannot be addressed on an urgent basis and will be attended to only as the doctor’s availability allows. Client Responsibilities You are responsible for helping the Agency maintain a respectful treatment environment. Adults and children are expected to act safely and appropriately towards all staff, family members, and other clients. Rude or obscene language, evidence of intoxication or substance abuse, and or verbal/physical threats will not be tolerated and may result in termination of services. Threats or actions against one’s self or others are not protected by confidentiality and may be reported to the appropriate authority. You are responsible for providing all financial information necessary for the Agency to provide services, including insurance coverage. You are responsible for payment at the time of service, unless otherwise arranged. 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 to promptly provide any changes in information that relates to treatment, billing and contact (e.g., name, address, telephone number, insurance, employment, family composition.) For clients under the age of 18, an accompanying adult must remain available during all appointments. You are responsible for keeping scheduled appointments. Please refer to the Agency’s Attendance Policy. Participation in any of the programs at Child and Family Agency is limited to the client, the client's guardian, Agency staff, and any other family member or service provider listed on the treatment plan. Participation in a session by any other individual may not occur without a signed written agreement between the client and the Agency. All treatment plans and treatment plan updates will be reviewed and rated every 90 days with client and caregivers, if applicable. Child and Family Agency constantly strives to create and refine more effective ways to help children and families across its many services. For this reason, we carefully evaluate the effectiveness of our programs and request your permission to use identifying information for internal agency research 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. Routine phone calls are not always able to be addressed the same day they are received. In an emergency, clients should contact their therapist, who will refer you to an emergency room if necessary. If the therapist is unavailable, the call can be directed to the Clinical Supervisor or the Clinical Director, who will assist you. Outside Office Setting Acknowledgment* I understand when services are provided outside of the office setting what is discussed between me, my family, the Child & Family Agency 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. Medication management* If you or your child receives medication management through the Agency, you are responsible to give your psychiatric provider seven days advance notice for medication refills. The Agency is not responsible for providing refills if less than seven days notice is given Medication appointments* The client and guardians must attend all scheduled medication appointments; as issues relevant to the client’s medication will be addressed at this time. This includes prescription refills and any necessary medical forms for school, camp, etc. This requires the client and guardian to plan ahead regarding concerns, forms, and prescription needs. If the client has taken medication as directed and attended scheduled medication follow-ups, then they should not run out of medication in between appointments. Medication safety* Medications must only be taken as prescribed. The client &/or guardian have a responsibility to notify their doctor of any side effects, significant changes in mood noticed, safety concerns, the use of alcohol or recreational drugs, new medical issues, or any other prescribed or over-the-counter medications the client is taking. Medication issues* It is expected that medication issues will be addressed during client appointments. If changes arise that necessitate psychiatric care prior to the client’s next appointment, call the front desk to schedule a visit sooner Missed appointments* The client &/or guardian are responsible for rescheduling any missed appointments Releases of information* Client &/or guardian receiving psychiatric medication only services through Child and Family Agency are responsible for providing releases of information to external treatment providers for coordination of care including, counseling, primary care, or other applicable service providers. Rights and responsibilities acknowledgement* I have read and/or discussed my rights and responsibilities with my assigned staff member and fully understand and agree to them. I hereby request services for myself/child/family. Notice of Privacy Practices PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND ACCESSED BY YOU. Click here to review the Agency's Privacy Practices Privacy practices acknowledgement* I acknowledge that I have reviewed Child & Family Agency of Southeastern CT, Inc.’s Notice of Privacy Practices currently in effect. Appointment confirmations* I agree to have my protected health information used to confirm appointments. This will involve leaving the name of the agency, clinician and site along with my appointment time. No, Please do not confirm appointments. Release of information and assignment of benefits Primary insurancePrimary insurance company name* Primary insurance policy # or member/subscriber ID* Primary insurance phone number*Primary insurance policy holder name* Primary insurance policy holder date of birth* MM slash DD slash YYYY Do you have a second insurance company?* Yes No Secondary insuranceSecondary insurance company name* Secondary insurance policy # or member/subscriber ID* Secondary insurance phone number*Secondary insurance policy holder name* Secondary insurance policy holder date of birth* MM slash DD slash YYYY Do you have a third insurance company?* Yes No Tertiary InsuranceTertiary insurance company name* Tertiary insurance policy # or member/subscriber ID* Tertiary insurance policy holder name* Tertiary insurance policy holder date of birth* MM slash DD slash YYYY AuthorizationsRelease of Information* I authorize the release of any medical or other information (including psychiatric, HIV and drug and/or alcohol related) necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment. Client or authorized person's 18 years of age or older signature for release of information* Date of Client or authorized person's signature for release of information* MM slash DD slash YYYY Payment authorization* I authorize payment of medical benefits to the assigned physician or supplier for services provided at Child & Family Agency of Southeastern Connecticut, Inc. Client or authorized person's 18 years of age and older signature for payment authorization* Date of Client or authorized person's signature for payment authorization* MM slash DD slash YYYY Financial responsibility agreement for counseling servicesChild and Family Agency (CFA) is a sliding fee scale agency. Our full fee per therapy session varies by service. Because CFA recognizes it would be a financial hardship for many clients to pay the full fee at each session, we have designed an alternative payment system, provided the client agrees to the following: I agree to submit accurate financial information as requested, i.e. third party coverage, Husky, Medicare, and household’s gross weekly income minus taxes. I agree to provide the agency with other documentation of income as may be necessary. I agree to provide CFA with a Husky or commercial insurance card upon the first visit. I agree to provide CFA with a signed major medical insurance form authorizing payment directly to the agency no later than my second visit and understand that I am responsible for any payment not met. For most programs, I understand that if my child is privately insured under a plan with a high deductible, I will be charged a $50.00 fee per session until the deductible has been met at which time a co-pay will be assessed based on my insurance plan. Should you need a fee adjustment, please discuss this with your child’s clinician. School-based health center services do not charge out-of-pocket fees, including co-pays or deductibles. Adult Outpatient Treatment Program is unable to adjust fees-- the full cost agreed to at intake must be paid for each session. I agree to pay my client fee at each visit, and if I miss one payment, I will remit payment at my next therapy session along with that session’s fee. If two payments are missed in a row, I understand I may be asked to reschedule any future appointment until payment is received. If I pay by check, I understand that I may be required to pay a $20.00 bank service charge if my check is returned for insufficient funds. Should that occur, I may be required to pay for future services in cash. I understand if my account is two or more payments in arrears, service may be suspended until such time as my account is paid in full. If you are in a financial crisis payment options are available. Below is the contact information for the billing department. I agree to notify CFA promptly of any change in my financial or insurance status which may/may not affect my fee. I understand that CFA has the right to request an update of my financial income information and to request validation of hardship before client fee is reduced. I agree to pay my patient responsibility after my insurance makes payment on services. I understand this amount is subject to change based on deductible, copayment and/or coinsurance. I understand I can contact the billing department and my clinician for questions and payment options. The billing department can be reached at (860)443-2896. If insurance coverage and Husky does not apply, a sliding scale fee will be determined by the billing department based on total household income and the number of household members. Financial responsibility acknowledgement* I have read and agree to the above applicable provisions. I understand that failure to comply with any of the above could result in service being terminated. Consent and notice regarding electronic signaturesElectronic Signature Agreement I give consent for myself and any minor child in my custody to Child and Family Agency of Southeastern Connecticut to collect an electronic signature on documents including but not limited to treatment such as assessments, treatment plans, and treatment plan updates. By signing below, I agree that my electronic signature is the equivalent of my manual signature. I further agree that the use of a keyboard and mouse to select an item and to collect the electronic signature constitutes my signature, acceptance and agreement as if actually signed by myself in writing. I further agree that each use of my e-signature in signing documentation constitutes my agreement to be bound by the terms and conditions of the Electronic Signature Agreement as it exists on the date of my e-signature. Revocation of Electronic Signature I understand that I have the right to withdraw my consent to electronically sign documents. Withdrawing consent can be completed by speaking with my Child and Family Agency staff in person or by phone. Electronic signature agreement acknowledgement* I have read and agree to the terms shown above. Consent to telehealth Telehealth allows CFA clinicians/practitioners to diagnose/evaluate, consult, treat, educate, and manage my care using interactive audio, video or data communication. I hereby consent to participating in psychotherapy, psychiatric evaluation and medication management via telephone or the internet (hereinafter referred to as Telehealth) with my CFA providers: I understand I have the following rights under this agreement: I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy and evaluation/medication management appointments. Any information disclosed by me during the course of my treatment, therefore, is generally confidential. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my therapist has the right to break confidentiality to prevent the threatened danger. Further, I understand that sharing of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my written consent. I agree not to record and/or distribute my telehealth therapy sessions. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that our telehealth appointments could be disrupted or distorted by technical failures or could be interrupted. You or your CFA provider(s) may determine that a higher level of care than Telehealth is required to meet your unique treatment needs, at which time a referral will be made to the appropriate provider. Refusal to participate in telehealth if no other type of service is available due to office closure, will result in referral to a higher level of care. I have read and understand the information provided above. I have the right to discuss any of this information with my clinician and to have any questions I may have regarding my treatment answered to my satisfaction. I understand that I can withdraw my consent to Telehealth communications at any time verbally and in writing. Telehealth agreement acknowledgement* I have read and agree to the terms shown above. Receive copy of this form (optional) You may receive a copy of this completed form in an email. Please be aware this form contains names, dates of birth, and policy numbers. This information is considered Protected Health Information and belongs to you. Email is not a secure method to receive this information. Only request this completed form if you understand the risk associated with email. You may request this completed form at any time by contacting the Child and Family Agency. See our contact information on our website. Send the completed form by email.* I understand the risk and assume responsibility. Do not send the completed form by email. Email* Enter Email Confirm Email School-Based Health Center ClientsBy signing below, I understand and acknowledge I have read and understand this consent: I give permission for my child/self to obtain routine health services at the School-Based Health Center.My child attendsSelect schoolBennie Dover Jackson Middle SchoolCatherine Kolnaski Magnet SchoolGrasso TechGroton Middle SchoolFitch Senior High SchoolHarbor Elementary SchoolJennings Elementary SchoolMystic River Magnet SchoolNathan Hale Elementary SchoolNew London High SchoolNortheast AcademyRegional Multicultural Magnet SchoolStonington Middle SchoolThames River Magnet SchoolThe Friendship SchoolWinthrop Elementary SchoolMy child does not attend one of these schoolsAll insurances will be billed at time of visit. No out-of-pocket costs for medical services rendered in school. No one will be refused services due to the inability to pay. Annual Risk Assessment Screening visits may be completed for healthy lifestyle assessment and are part of the best practice guidelines for medical care. Parents/guardians will be notified before screening visit. Annual Risk Assessment Screening Visits Check box to opt OUT AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMTION I give permission to allow Child & Family Agency (CFA) to exchange as needed information with my child's medical provider, school nurse, and key school personnel in order to effectively care for my child. I understand that SBHC medical and mental health providers may communicate with each other about my child's care if indicated.Client or authorized person's 18 years of age or older signature for exchange of Health and Education Information* Date of authorization for exchange of Health and Education Information MM slash DD slash YYYY Client or authorized person's 18 years of age or older name First Last Client or authorized person's 18 years of age or older signature Date of signature MM slash DD slash YYYY 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 updated 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 Right and Privacy Act.
