Step 1 of 6 – Healthy Futures Intake 16% Name First Last Healthy FuturesAdult InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender Female Male Non-Binary Prefer not to say Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Phone(Required)Email Race/Ethnicity Mexican, Mexican American, or Chicano Puerto Rican Cuban Another Hispanic, Latino, or Spanish Origin American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Primary Language(Required) English Spanish Other Marital Status Single Married Divorced Widowed Are you a parent or caregiver?(Required) Yes No Are you a first time parent?(Required) Yes No Does your child live with you?(Required) Yes No N/A Are you pregnant?(Required) Yes No N/A How many weeks are you?(Required) What is your due date?(Required) MM slash DD slash YYYY Are you receiving prenatal care?(Required) Yes No N/A Are you employed? Yes No How many hours per week do you work? Are you enrolled in an education or training program? Yes No N/A Child InformationChild NameFirstLastDate of Birth Add RemoveChild address, if different from adult Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Employment and Referral InformationLearn about child development and parenting? Yes No Support and Information on family planning? Yes No Support for meeting economic/housing needs? Yes No Support for mental health and well being? Yes No Support for education attainment or employment? Yes No Increase social support? Yes No Support obtaining healthcare or health insurance? Yes No Referral Source Agency referral Self referral Referral source name Referral source phone numberReferral source email Reason for Referral Doula support (Prenatal support/delivery education or support) Group parent support In-home parent support Other Please explain other reason for referral(Required)Participant ConsentAgency Client Grievance Procedures(Required)Click here to review the Grievance Procedures online. I acknowledge reading the Agency’s Client Grievance Procedures Signature(Required) Today's Date(Required) MM slash DD slash YYYY 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 gaffneye@childandfamilyagency.org) 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) MM slash DD slash YYYY 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) MM slash DD slash YYYY Client signature(Required) Guardian Signature AUTHORIZATION FOR THE RELEASE OF INFORMATIONIs a Release of Information Needed?(Required) Yes No Client Name(Required) First Last Client date of birth(Required) MM slash DD slash YYYY Client PhoneClient Email Relation to person granting permission Self Dependent Are there additional subjects of PHI release?(Required) Yes No List(Required)First and Last NameDate of BirthRelation to person granting permission Add RemoveType of Release(Required) Authorization for Release of Protected Health Information Authorization for Release of Protected Health Information to DCF Authorization for Release of PHI to DCF-ACR/Permanency Team Is this release for a school district?(Required) Yes No Name and/or Organization of Information Recipient(Required) Address(Required) City AlabamaAlaskaAmerican 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 Please specify the recipient information and/or individuals that may obtain or release the information according to the limitations described below.*(Required) Recipient information School Nurse(s) (with the understanding that some school nurses are employed by other entities, such as the VNA of Southeastern CT, etc.) Authorization for Release of Protected Health Information for participation in PPT-504 multi-disciplinary meetings (Optional) Youth Officer(s) assigned to this student’s school Please specify the information recipient, in addition to Case Involved Staff, that may obtain or release the information according to the limitations described(Required) Please specify the information recipient, in addition to Case Involved Staff, that may obtain or release the information according to the limitations described(Required) School District Name(Required) School District Location(Required) City AlabamaAlaskaAmerican 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 CT Department of Children & Families Street Address Address Line 2 City AlabamaAlaskaAmerican 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 Types of Record(s) to be released (check all that apply): Psychiatric Medical Education Psychotherapy Summary Documents Other Describe other record(s) to be released(Required)I specifically authorize release of the following sensitive information from my/my child's record Substance abuse (alcohol/drug) Confidential HIV/AIDS related information Purpose of authorization/disclosure(Required) Ongoing service planning and coordination Purpose of authorization/disclosure(Required) Ongoing service planning and coordination Provision of information to DCF staff (e.g. caseworkers; supervisors) and DCF’s agents and legal representatives regarding client participation in Child and Family Agency’s services and progress on service goals. Nature and extent of information to be disclosed(Required) Entire medical record Limited health information Describe limited health information (e.g. attendance and dates of service)Please specify the time period the disclosed information should relate to:(Required) No limitations on time frame Only time frame specified below Time frame starting on:(Required) MM slash DD slash YYYY Time frame ending on:(Required) MM slash DD slash YYYY By signing below, I understand and acknowledge the following: I understand this authorization will expire one year from date signed, unless cancelled. I understand that refusal to sign this authorization form will not affect my right to obtain present and future services, except where disclosure of the records requested is necessary for services. I also understand that I may revoke this authorization by notifying Child and Family Agency of the named recipient in writing. A revocation of this authorization will not apply to any records disclosed before the authorization is revoked. Pursuant to C.G.S. 17a-28(k) the information disclosed pursuant to this authorization is not subject to re-disclosure by the recipient without a separate authorization for that purpose except as provided by said statute. Electronic signature of person authorizing disclosure or authorized representative(Required) Today's Date(Required) MM slash DD slash YYYY Check below if this form has been signed by a person other than the subject of the record Parent/Guardian Attorney Guardian ad litem Other Explain other relationship to subject of the record(Required) Note: Confidentiality of psychiatric, drug and/or alcohol abuse, and HIV records is required and no information from these specific records shall be transmitted to anyone else without written consent or authorization under Connecticut General Statutes, Chapters 899c and 368x and Federal Regulations 42 CFR 2. These laws prohibit the recipient of the record from making any further disclosure without specific written consent of the person to whom the record pertains. A general authorization of the release of this information is NOT sufficient for this purpose. INFORMED 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: Client Name(Required) First Last Client Date of Birth(Required) MM slash DD slash YYYY Client signature(Required) Date of client signature(Required) MM slash DD slash YYYY Signature for Parent/Guardian (if client under 18) Date of Signature for Parent/Guardian (if client under 18) MM slash DD slash YYYY 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(Required) I acknowledge that I have reviewed Child & Family Agency of Southeastern CT, Inc.’s Notice of Privacy Practices currently in effect. Appointment confirmations(Required) 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. 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) MM slash DD slash YYYY 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 No 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 No 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) MM slash DD slash YYYY
