I understand that:
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.
Child 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:
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
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 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.
Electronic 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.
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.