Statement of custody, application for service and service agreement

STATEMENT OF CUSTODY, APPLICATION FOR SERVICE and SERVICE AGREEMENT

I understand that:

1. Services may include individual therapy, family therapy, group therapy, psychiatric evaluation and medication management.
2. Child and Family Agency does not dispense medication.
3. 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.
4. The Agency is open Monday through Friday, between the hours of 9:00 and 5:00, with additional hours varying by site. In case of urgent/emergent concerns after office hours, the agency provides 24/7 on call support. The on call clinician can be reached by calling 860-823-0893. For life threatening emergencies, families should call 911 immediately.
5. 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.
6. Parents/Guardians with clients under the age of 12 must accompany the child to the appointment and remain in the waiting room. It has been explained to me and the minor client that if he/she becomes uncomfortable during a session he/she may leave the office at any time and come to me in the waiting room. All parents/guardians may be asked to accompany clients or remain with the client when deemed appropriate by the therapist.
7. My signature below acknowledges I am in receipt of the Agency’s Client Grievance Procedures.
8. My signature below acknowledges that I am in receipt of, have reviewed, and will comply with the Agency’s Attendance Policy.