Forms – Client R&R Medication Management

Client Rights & Responsibilities – Psych Med. Management (rev 20200914)

Client Rights & Responsibilities – Psych Med. Management rev 2020-09-14

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.

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 Acknowledgement*
- 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.
Client name*
First Last
Client signature*
Client date of birth*
MM slash DD slash YYYY
Parent/Guardian signature
Today's date*
MM slash DD slash YYYY

Client Rights & Responsibilities – Psych Med. Management (rev 20200914)

Client rights and responsibilities

Psychiatric medication management