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Child and Family Agency

Child and Family Agency

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Healthy Futures Intake


Step 1 of 5 - Healthy Futures Intake

20%

Healthy Futures

Adult Information

Name(Required)
MM slash DD slash YYYY
Gender
Address(Required)
Race/Ethnicity
Primary Language(Required)

Marital Status
Are you a parent or caregiver?(Required)
Are you a first time parent?(Required)
Does your child live with you?(Required)
Are you pregnant?(Required)
MM slash DD slash YYYY
Are you receiving prenatal care?(Required)
Are you employed?
Are you enrolled in an education or training program?

Child Information

Child Name
First
Last
Date of Birth
 
Child address, if different from adult

Employment and Referral Information

Learn about child development and parenting?
Support and Information on family planning?
Support for meeting economic/housing needs?
Support for mental health and well being?
Support for education attainment or employment?
Increase social support?
Support obtaining healthcare or health insurance?
Referral Source
Reason for Referral

Participant Consent

Agency Client Grievance Procedures(Required)
Click here to review the Grievance Procedures online.
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)
MM slash DD slash YYYY
For caregivers who are transferring from one home visiting program to another, or who are re-enrolling in home visiting:
MM slash DD slash YYYY

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Is a Release of Information Needed?(Required)
Client Name(Required)
MM slash DD slash YYYY
Relation to person granting permission
Are there additional subjects of PHI release?(Required)
List(Required)
First and Last Name
Date of Birth
Relation to person granting permission
 
Type of Release(Required)
Is this release for a school district?(Required)
Address(Required)
Please specify the recipient information and/or individuals that may obtain or release the information according to the limitations described below.*(Required)
School District Location(Required)
CT Department of Children & Families
Types of Record(s) to be released (check all that apply):
I specifically authorize release of the following sensitive information from my/my child's record
Purpose of authorization/disclosure(Required)
Purpose of authorization/disclosure(Required)
Nature and extent of information to be disclosed(Required)
Please specify the time period the disclosed information should relate to:(Required)
MM slash DD slash YYYY
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.

MM slash DD slash YYYY
Check below if this form has been signed by a person other than the subject of the record
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)
MM slash DD slash YYYY
MM slash DD slash YYYY
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)
Appointment confirmations(Required)

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