Notice Regarding the Use and Disclosure Of Protected Health Information

Effective July 1, 2013

This notice describes how we, Child and Adolescent Behavioral Health, use or disclose your Protected Health Information (“PHI”). PHI is information that identifies you and relates to health care services, the payment of health care services or your physical or mental health or condition, in the past, present or future. This notice also describes your rights to access and control your PHI.

Our Responsibilities

Federal law requires that we maintain the privacy of your PHI and provide to you with this Notice of our legal duties and privacy practices. We are required to notify affected individuals following a breach of unsecured PHI. We are required to abide by the terms of this Notice, which may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that we maintain. We will promptly revise and distribute this Notice whenever there is a material change to the uses or disclosures, your rights, our duties, or other practices stated in this Notice. Except when required by law, a material change to this notice will not be implemented before the effective date of the new notice in which the material change is reflected.

How We May Use or Disclose PHI for Treatment, Payment, and Health Care Operations

 For Treatment. We may use and disclose your PHI to coordinate or manage your care within Child and Adolescent Behavioral Health and with individuals or organizations outside of Child and Adolescent Behavioral Health that are involved in your care, such as your attending physician, other health care professionals, contracted service providers or related organizations. For example, certain service providers involved in your care may need information about your medical condition in order for us to deliver services properly and appropriately.

To Obtain or Provide Payment. We may include your PHI in invoices to collect or provide payment to or from third parties for the care you receive through Child and Adolescent Behavioral Health. For example, some PHI is transmitted to the Ohio Department of Aging and the Ohio Department of Job and Family Services when billing transactions are conducted.

To Conduct Health Care Operations. We may use and disclose PHI for our own operations and as necessary to provide quality care to all of our service recipients. Health care operations include but are not limited to the following activities: quality assessment and improvement activities; activities designed to improve health or reduce health care costs; protocol development, case management and care coordination; professional review and performance evaluation; review and auditing, including compliance reviews, medical reviews, legal services and compliance programs; and business management and general administrative activities of Child and Adolescent Behavioral Health. For example, we may use PHI to evaluate our staff performance or combine your health information with other consumer PHI to evaluate how to better serve all of our consumers. Another example may be the disclosure of your PHI to staff or contracted personnel for certain limited training purposes.

How We May Use or Disclose PHI for Appointment Reminders, Treatment Alternatives, or Fundraising Activities

 We may use and disclose your PHI to contact you as a reminder that you have an appointment for a home visit. We may use and disclose your PHI to advise you or recommend possible service options or alternatives that may be of interest to you. We may contact you for fundraising activities. However, you will be provided the opportunity to opt out of receiving such fundraising communications.

Disclosures You May Authorize Us to Make

We will not use or disclose your PHI without authorization, except as described in this Notice.

Most uses and disclosures of psychotherapy notes, as applicable, require your authorization. Subject to certain limited exceptions, we may not use or disclose PHI for marketing without your authorization. We may not sell PHI without your authorization. You may give us written authorization to use and/or disclose health information to anyone for any purpose. If you authorize us to use or disclose such information, you may revoke that authorization in writing at any time.

Other Specific Uses or Disclosures

When Legally Required. We will disclose your PHI when required by any Federal, State or local law.

In the Event of a Serious Threat to Life, Health or Safety. We may, consistent with applicable law and ethical standards of conduct, disclose your PHI if we, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to your life, health, or safety, or to the health and safety of the public.

When There Are Risks to Public Health.  Child and Adolescent Behavioral Health may disclose your PHI for public activities and purposes allowed by law in order to prevent or control disease, injury or disability; report disease, injury, and vital events such as birth or death; conduct public health surveillance, investigations, and interventions; or Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

To Report Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe a consumer is the victim of abuse, neglect or domestic violence. We will make this disclosure only when required or authorized by law, or when the consumer agrees to the disclosure.

To Conduct Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. However, we may not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits.

In Connection With Judicial and Administrative Proceedings. We may disclose your PHI in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order, or, in response to a subpoena, discovery request or other lawful process, if we determine that reasonable efforts have been made by the party seeking the information to either notify you about the request or to secure a qualified protective order regarding your health information. Under Ohio law, some requests may require a court order for the release of any confidential medical information.

For Law Enforcement Purposes. As permitted or required by law, we may disclose specific and limited PHI about you for certain law enforcement purposes.

For Research Purposes. We may, under very select circumstances, use your PHI for research. Before we disclose any of your PHI for such research purposes in a way that you could be identified, the project will be subject to an extensive review and approval process, unless otherwise prohibited as with Medicaid.

For Specified Government Functions. Federal regulations may require or authorize us to use or disclose your PHI to facilitate specified government functions relating to military and veterans; national security and intelligence activities; protective services for the President and others; medical suitability determinations; and inmates and law enforcement custody.

For Workers’ Compensation. We may use or disclose your PHI for workers’ compensation or similar programs.

Transfer of Information at Death. In certain circumstances, we may disclose your PHI to funeral directors, medical examiners, and coroners to carry out their duties consistent with applicable law.

Organ Procurement Organizations. Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purposes of tissue donation and transplant.

Your Right with Respect to PHI

You have the following rights regarding PHI that we maintain:

Right to a Personal Representative. You may identify persons to us who may serve as your authorized personal representative, such as a court-appointed guardian, a properly executed and specific power-of-attorney granting such authority, a Durable Power of Attorney for Health Care if it allows such person to act when you are able to communicate on your own, or other method recognized by applicable law. We may, however, reject a representative if, in our professional judgment, we determine that it is not in your best interest.

Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on our disclosure of your PHI to someone who is involved in your care or the payment of your care. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it unless the request concerns a disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full. To request such restrictions, please contact your C&A (Child and Adolescent Behavioral Health) provider or Privacy Official at 330-454-7917.

Right to Receive Confidential Communications. You have the right to request that we communicate with you in a confidential manner. For example, you may ask us to conduct communications pertaining to your health information only with you privately, with no other family members present. If you wish to receive confidential communications, please contact your C&A provider or Privacy Official at 330-454-7917.  We may not require that you provide an explanation for your request and will attempt to honor any reasonable requests.

Right to Inspect and Copy Your PHI. Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your PHI upon request. You have the right to inspect and copy such health information, including billing records, at a reasonable time and place. A request to inspect and copy records containing your PHI may be made to your C&A provider or Privacy Official at 330-454-7917. If you request a copy of such health information, we may charge reasonable copying, processing, and personnel fees.

Right to Amend Your PHI. You have the right to request that we amend your records, if you believe that your PHI is incorrect or incomplete. That request may be made as long as we maintain the information. A request for an amendment of records must be made in writing to your C&A provider or Privacy Official at Child and Adolescent Behavioral Health, 919 2nd Street NE, Canton, Ohio, 44704.  We may deny the request if it is not in writing, or does not include a reason for the amendment. The request also may be denied if your health information records were not created by us, if the records you are requesting are not part of our records, if the health information you wish to amend is not part of the health information you are permitted to inspect and copy, or if, in our opinion, the records containing your health information are accurate and complete. We take the position that amendments may take the form of including a written statement from you and may not include changing, defacing or destroying any necessary information related to your health care.

Right to Know What Disclosures Have Been Made. You have the right to request an accounting of disclosures of your PHI made by us for certain reasons, including reasons related to public purposes authorized by law, and certain research. The request for an accounting must be made in writing to your C&A provider or Privacy Official at Child and Adolescent Behavioral Health, 919 2nd Street NE, Canton, Ohio 44704.  The request must specify the time period for the accounting starting on or after April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years prior to the date on which the accounting is requested. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable, cost-based fee.

Health Information Exchanges. We participate in one or more Health Information Exchanges. Your healthcare providers can use the CliniSync electronic network to securely provide access to your health records for a better picture of your health needs. We and other healthcare providers may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying the Medical Records Department.

Right to a Paper Copy of This Notice. You have a right to receive paper copy of this Notice at any time, even if you have received this Notice previously. To obtain a paper copy, please contact your C&A provider or Privacy Official at 330-454-7917.

Where to File a Complaint

You have the right to complain to us if you believe that your privacy rights have been violated, including the denial of any rights set forth in this Notice. Any complaints to us shall be made in writing to your C&A provider or the Privacy Official at Child and Adolescent Behavioral Health, 919 2nd Street NE, Canton, Ohio 44704.  We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C., 20201 or call toll-free (877) 696-6775, by e-mail to, or to Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, Ill. 60601, Voice Phone (312) 886-2359, FAX (312) 886-1807, or TDD (312) 353-5693.

Contact Persons

We have designated the Privacy Official as our contact point for all issues regarding consumer privacy and your rights under this Notice. If you have any questions regarding this Notice, please contact your C&A provider or Privacy Official at 330-454-7917 x 134.

Effective Date

This Notice is effective July 1, 2013.

If You Have Any Questions Regarding This Notice, please contact your C&A provider or Privacy Official at 330-454-7917.



All Child and Adolescent Behavioral Health employees and workers located at any site where services or treatment are provided will always strive to provide you , the individual or family who comes to us for assistance, with quality, timely services in a setting you find friendly and supportive.  As someone who receives services from our agency, you are entitled, by law, to the opportunity to know and understand your rights and responsibilities according to law and to Child and Adolescent Behavioral Health policy.  The following information is provided for your reference.  Please do not hesitate to call or write us if you have any questions or concerns.

    1. “Client” means an individual applying for or receiving mental health services.
    2. “Client Rights Officer” means the individual designated by a mental health agency with responsibility for assuring compliance with the client rights and grievance procedure rule as implemented within the agency.
    3. “Contract Agency” means a public or private service provider with which community mental health board enters into a contract for the delivery of mental health services.
    4. “Grievance” means a written complaint initiated either verbally or in writing by a client or by any other person or agency on behalf of a client regarding denial or abuse of any client’s rights.
    5. “Reasonable” means a standard for what is fair and appropriate under usual and ordinary circumstances.
    6. “Services” means the complete array of professional interventions designed to help a person achieve improvements in mental health such as counseling, individual therapy, group services, education, therapeutic behavioral services, community psychiatric supportive treatment, assessment, diagnosis, treatment planning and goal setting, clinical review, psychopharmacology, discharge planning, and/or professionally-led support.
    1. The right to be informed of the rights described in this rule prior to consent to proceed with services, and the right to request a written copy of these rights;
    2. The right to receive information in language and terms appropriate for the person’s understanding;
    3. The right to be fully informed of the cost of services;
    4. The right to be treated with consideration, respect for personal dignity, autonomy, and privacy, and within the parameters of relevant sections of the Ohio Revised Code and the Ohio Administrative Code;
    5. The right to receive humane services;
    6. The right to participate in any appropriate and available service that is consistent with a behavioral health service plan (BHSP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person’s participation;
    7. The right to reasonable assistance, in the least restrictive setting;
    8. The right to reasonable protection from physical, sexual and emotional abuse, inhumane treatment, assault, or battery by any other person;
    9. The right to a current BHSP that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services, as available, either directly or by referral;
    10. The right to actively participate in periodic BHSP review with the staff including services necessary upon discharge;
    11. The right to give full informed consent to any service including medication prior to commencement and the right to decline services including medication absent an emergency;
    12. The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies or photographs, or other audio and visual technology. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms;
    13. The right to decline any hazardous procedures;
    14. The right to be free from restraint or seclusion unless there is imminent risk of physical harm to self or others;
    15. The right to reasonable privacy and freedom from excessive intrusion by visitors, guests and non-agency surveyors, contractors, construction crews or others;
    16. The right to confidentiality unless a release or exchange of information is authorized and the right to request to restrict treatment information being shared;
    17. The right to be informed of the circumstances under which an agency is authorized or intends to release, or has released, confidential information without written consent for the purposes of continuity of care as permitted by division (A) (7) of section 5122.31 of the Revised Code;

ORC 5122.31(A)(7) “That hospitals within the department, other institutions and facilities within the department, hospitals licensed by the department under section 5119.20 of the Revised Code, and community mental health agencies may exchange psychiatric records and other pertinent information with payers and other providers of treatment and health services if the purpose of the exchange is to facilitate continuity of care for a patient.”

  1. The right to have the grievance procedure explained orally and in writing; the right to file a grievance with assistance if requested; and the right to have a grievance reviewed through the grievance process, including the right to appeal a decision;
  2. The right to receive services free of discrimination on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, human immunodeficiency virus status, genetic information, or in any manner prohibited by local, state, or federal laws;
  3. The right to exercise rights without reprisal in any form including the ability to continue services with uncompromised access. No right extends so far as to supersede health and safety considerations;
  4. The right to have the opportunity to consult with independent specialists or legal counsel at one’s own expense;
  5. The right to have no conflict of interest – i.e., no agency employee may be a person’s guardian or representative if the person is currently receiving services from said facility;
  6. The right to have access to one’s own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual client for clear treatment reasons in the client’s treatment plan. If access is restricted, the treatment plan shall also include a goal to remove the restriction;
  7. The right to be informed in advance of the reason(s) for discontinuance of that event;
  8. The right to receive an explanation of the reasons for denial of service.
    1. The grievance procedure shall be posted in a highly visible place in each agency location.
    2. Upon request, All Child and Adolescent Behavioral Health (C&A) clients and/or guardians shall be provided with oral and written instructions for filing a grievance. Any C&A client/guardian who has a concern, complaint, or grievance should contact Client Rights Officer, Kimberly Cernansky at Child and Adolescent Behavioral Heath, 1207 W State St STE G Alliance, Ohio 44601, 330-823-5335 Ext 309 ,or Alternate Client Rights Officer, Colin Christensen, 330-433-6075, Ext. 207.  Business hours are Monday – Friday, 9:00 a.m. – 5:00 p.m.
    3. C&A staff provide the Client Rights Advocate with accessibility and all necessary steps to assure compliance with the grievance procedure. Alternative arrangements will be made if the Client Rights Officer is the subject of grievance.
    4. Any person (client/family/other) who has a concern, complaint or grievance shall immediately be provided with the name and phone number of the agency Client Rights Officer (Kimberly Cernansky, 330-823-5335, Ext. 309). The Client Rights Officer and/or Alternate Client Rights Officer (Colin Christensen, 330-433-6075, Ext. 207) will assist the griever in resolving the concern through the following steps:
    5. C&A clients/guardians shall attempt to discuss any concerns with the source of that concern.
    6. If the C&A client/guardian is not satisfied, he/she will contact and/or meet with the immediate supervisor/designee within two (2) working days. The supervisor may also meet with the supervisee. The Chief Executive Officer and the Client Rights Officer shall be notified of the concern.
    7. If the C&A client’s concern remains unresolved, the client/guardian shall meet with the appropriate administrator/department head/designee, within two (2) working days.
      1. Immediately following the client’s meeting with the administrator/department head/designee, the Client Rights Officer/designee shall meet with the client and with the administrator/department head/designee to (a) ascertain that a resolution has been reached or (b) if no resolution has occurred, to determine what concerns still exist and to attempt to resolve those concerns.
    8. If the C&A client’s/guardian/s concerns still remain unresolved, the Client Rights Officer/designee shall assist the client/guardian in preparing and submitting a written statement to the Chief Executive Officer within three (3) working days.
    9. The Chief Executive Officer, as an impartial decision-maker, shall meet with the client/guardian and then shall confer with the Chief Operating Officer and Client Rights Officer as part of the resolution.
      1. Within three (3) working days, the Chief Executive Officer will convey his decision, in writing, to the client/guardian.
      2. If the C&A client/guardian is still not satisfied, he/she may address an Ad Hoc Committee composed of a member of the Board of Trustees, the Chief Executive Officer, the Client Rights Officer and an impartial agency administrator. The committee will meet and deliver a decision within ten (10) working days.
    10. After each attempt to resolve the client’s grievance, the Client Rights Officer/designee will give the client written notification and an explanation of the resolution.
    11. Upon written request of the client, information may be released regarding the grievance.
    12. All C&A clients/guardians shall be provided the opportunity to file a grievance within a reasonable period of time or as mandated by law (particularly in the case of children), from the date the grievance occurred and a time line not exceeding twenty (20) working days from the date of filing the grievance until a resolution of the grievance within this agency.
      1. All C&A clients/guardians shall have the option to register a complaint with any or all, but not exclusively, the following:
      2. Stark County Mental Health & Addiction Recovery, 121 Cleveland Ave. SW, Canton, Ohio 44702.  Telephone:  330-455-6644.
      3. Ohio Department Mental Health and Addiction Services, 30 East Broad Street, Columbus, Ohio 43215.  Telephone:  614-466-2333.
      4. Disability Rights Ohio, 200 Civic Center Drive, Suite 300, Columbus, Ohio 43215.  Telephone:  1-800-282-9181.
      5. U. S. Dept. Of Health and Human Services, Regional Office, 233 N. Michigan Avenue, Chicago, IL 60601.  Telephone:  312-886-2359.
    13. Appropriate professional licensing, regulatory associations and/or other State Departments. The names, addresses and phone numbers of the aforementioned will be given to the griever upon request.
    In addition to the Client Rights, Child and Adolescent Behavioral Health shall observe the following:
  2. All BHSPs are reviewed according to Quality Assurance Standards.
  3. All policies and procedures affecting treatment will be explained to the individual/family/guardian in a language that the individual/family/ guardian can understand.
  4. Any individual with a hearing impairment will be provided with an interpreter and other auxiliary aids when necessary to afford such person an equal opportunity to benefit from services, at no cost to the individual. If such assistance or aids are necessary, the client/guardian shall inform C&A staff. (Refer to OL 14.39, Language Access Plan)
  5. Any client/family/guardian whose primary language is not Standard English will be provided with an interpreter at the agency’s expense. Some documents are available in Spanish.
  6. Each client/family/guardian shall be provided information regarding the expectation, responsibilities, and privileges of the client.
  7. Each client/family/guardian shall be provided information regarding rules of the program and consequences for breaking these rules.
  8. With authorization, referral source(s) may be notified of an individual’s termination or suspension from treatment (i.e., Department of Jobs and Family Services, Criminal Justice Authority, School).
  9. The individual/family/guardian has a right to request a change of service provider.
  10. The individual/ family/guardian has a right to support from an adult advocate who will express and pursue the wishes of the child or adolescent, and who will employ procedural safeguards when fundamental rights and interests are threatened.
  11. All C&C employees shall act in accordance with the law to protect individuals from abusive neglectful and endangering situations.
  12. Appropriate local, state, and federal regulations pertaining to nondiscrimination shall be posted where visible to clients and public.
  13. In case of emergency, clients/parent/guardians will at the least be informed of their rights to accept or reject any service.
    1. All C&A Clients and/or current guardians have the following rights with regards to access of clinical records:
  15. The right to receive written clinical information included in the designated record set following a completed authorization to release information signed by the current legal guardian. The request will be responded to within ten (10) working days, if possible.  Information in the record from other sources may be released only with an appropriate specific release of information form signed by the legal guardian;
  16. The right to have no written clinical information released to any outside party unless written authorization is given by the client or legal guardian or mandated by law; and
  17. The right to challenge information in their child’s clinical record and to request an unbiased investigation of the accuracy of the information in question.  The client/ guardian may request to insert a statement of clarification or amendment in the client’s clinical record.

I hereby grant permission to provide initial and ongoing evaluations and treatment as may be deemed necessary or advisable for diagnosis and/or care of  (Client Name).  I understand that this consent shall remain valid so long as I am enrolled in Child and Adolescent Behavioral Health (C&A) services or until I withdraw consent.  I understand that all information gathered during my treatment at C&A is confidential.  However, confidential information may be disclosed without my consent in accordance with state and federal law.  Examples of such disclosures include situations of an emergency involving a serious and imminent threat to a person or the public; the reporting of child or adult abuse or neglect; court ordered disclosures; financial claims requirements and audit and program evaluations.  I understand that for purposes of my treatment, my treatment information may be discussed by other members of my Clinical Team, and other professionals at C&A.  Additionally, I understand that by signing this consent I am giving permission for the Stark County Mental Health and Addiction Recovery to access my information and records maintained by C&A and/or its subcontracted providers concerning the provision of covered services. I consent to have my data shared with the Ohio Department of Mental Health and Addiction Services for funding and reporting purposes.

I understand that the philosophy of care at C&A includes the belief that people should be treated in the least restrictive environment and that staff do not provide any physical (unless permission has been granted and documented according to Ohio law), mechanical, or chemical restraints.  Staff are trained to intervene when necessary, using non-physical techniques in an attempt to calm an escalating situation and will call the police if anyone’s physical safety is at risk.

I agree to participate in my treatment planning process to the best of my ability.

By signing this form, I understand that I am giving consent to receive evaluation and treatment services in accordance with the information described below.

  • I will provide/have provided a medical history that is true and complete to the best of my knowledge.
  • I understand that my providers will provide me with information about the diagnosis and proposed treatment.
  • I understand that my provider will provide me with information about the intended outcome and all available procedures involved in the proposed treatment.
  • I understand that my provider will inform me of any additional risks, including any side effects of the proposed treatment.
  • I understand that my provider will inform me of the risks of not proceeding with the proposed treatment
  • I understand that my provider will inform me of any alternatives to the proposed treatment including those offering less risk or fewer adverse effects.
  • I understand that my provider will provide me with a description of any clinical factors that might require suspension or termination of the proposed treatment.
  • I understand that any consent given may be withheld or withdrawn in writing at any time and will be documented in the medial record.
  • I understand that a photo may be kept on file for identification purposes.
  • I understand that if consent is revoked, treatment must be promptly discontinued, except in cases in which abrupt discontinuation of treatment may pose an immediate risk.  In such cases, I understand that treatment may be phased out to avoid any harmful effects.
  • I understand that all information gathered in the course of treatment is confidential and will not be disclosed without my permission except as allowed by law.

 Client Orientation

ASSESSMENT:  An Initial Service Goal for the first few sessions is to complete a comprehensive clinical assessment of you or your child.  Background information and presenting concerns regarding you or your child and family are gathered to determine the best treatment options for you or your child.  Assessment involves clinical interviews of you or your child and family members and will involve the use of rating scales.  Psychological testing may also be requested.  Areas of assessment will include:

  • Presenting symptomatology and concerns
  • Relationships with family and friends
  • Parenting styles
  • Areas of strength and success
  • Feelings about self and others
  • Behavior at home, in school, and in the community

SERVICE PLAN:  The assessment process helps us to collaboratively develop a Service Plan which specifies the goals and objectives of treatment and to what frequency agency services will be provided.  Because your involvement in this ongoing process is critical to the quality care and treatment outcomes of you or your child, failure to participate may result in the suspension or termination of services.

  • Parent(s)/guardian(s) and/or the client participate in creating the treatment goals and objectives
  • Parent(s)/guardian(s) and/or the client help determine if progress is being made
  • With your permission, others may be invited to assist in creating the Service Plan

BEHAVIORAL HEALTH SERVICES:  Counseling (Individual, Family, and/or Group Therapy), Case Management, Peer, Psychological Assessment, and Psychiatric services can differ depending on the needs of the client and/or client and family.

  • Frequency of appointments is based on the Service Plan
  • Location of appointments may include: our office, your home, your child’s school.  We will try to be flexible to best meet scheduling and treatment needs
  • Most appointments last 1-2 hours; school-based appointment times may vary
  • Parent(s)/guardian(s) involvement and active participation is essential.  You may be asked to meet with your service provider alone or with your child present
  • You may be asked to make changes of your own in order to contribute to your child’s progress

MEASURING PROGRESS:  We use several survey tools to measure progress throughout treatment.  You and your child (if age 8 and older) will be asked to complete the tool at the beginning of services and over the course of treatment.  By doing so, you will help us identify the progress you or your child has made, areas needing improvement, and your overall satisfaction with our agency.

Attendance Policies and Expectations

It is the expectation of C&A that clients attend all appointments as scheduled. People miss appointments when other things take priority over meeting with their service providers, or when they are physically prevented from meeting. Clients may miss appointments for crises, transportation problems, when they do not value the time with their provider enough to give up other activities, when they can’t afford our fees, or because they’ve decided not to make the changes we’re recommending. Whatever the reason, continuing to schedule with families who repeatedly miss appointments is neither responsive to their situations nor an effective use of our resources. Thank you for your understanding and your commitment to making improvements in your life and/or the life of your child.

Our most important goal at C&A is to provide you and your family with the help you are seeking. Attending each of your scheduled appointments gives us the best opportunity to do this. We understand there are circumstances, including family emergencies, transportation problems, and illnesses, which make it necessary to cancel an appointment. When this occurs, we ask that you do so with as much notice as possible, preferably at least 24 hours. This advanced notice allows us the opportunity to see other children and families who are waiting for our assistance.

Sometimes attendance is affected when families feel they are not getting the results they hope for or expect. This can happen for many reasons, including that your provider’s approach is not a “good fit” for you or your child and/or family. If this occurs, we encourage you to talk to your provider. Our staff are very knowledgeable  and understanding of the importance of a good relationship in helping children and families and want to know if you feel this way. If you wish, you may also contact your provider’s supervisor.

Regardless of the reasons for missing the appointments, cancellations, and/or no-shows make it difficult to help you or your child and family, and the many others we serve. Still, we want to continue to make our services available to you. To help us accomplish this, we have created the following No Show/Cancellation procedure:

  1. If the following occurs, we will no longer schedule regular appointment times with that provider, and ongoing appointments will be scheduled on a same-day call-ahead basis: a family/client no-shows/late cancels (less than 24-hour notice) two (2) appointments over a 90-day period; OR A family/client cancels three (3) appointments over a 90-day period.
  2. No-shows or cancellations will be discussed with your clinical team regarding your commitment to continuing treatment services.

Important Reminder: If you miss an appointment, please contact us to reschedule. If you do not contact us within 30 calendar days, we will assume you have decided to discontinue services. You are welcome to contact us anytime in the future and request that services resume. If you do return, please keep in mind, it will be important for you to be able to make a commitment to keeping all appointments.

At C&A, our clinical and support teams are here to assist you. In addition to our psychiatrist, nurse practitioners, licensed therapists, case managers, peer support specialists, and prevention specialists, our team includes schedulers and engagement specialists to help you access the services you need and want.

Due to current extremely high demand for our services and the challenge of finding enough licensed and qualified staff to meet that demand, we have implemented these attendance policies in order to provide care for those requesting our services.

  • All new and follow up appointments will be scheduled by scheduling staff. Clinical staff are not permitted to schedule appointments.
  • Clients are permitted to schedule up to two (2) subsequent appointments with their therapist, case manager, or peer specialist after each kept appointment, as long as scheduled appointments are attended, and the cancellation/no-show conditions are not met.
  • Appointments canceled with less than 24-hours’ notice will be considered a no-show
  • Clients who do not attend a scheduled appointment will be contacted by an engagement specialist to determine the reason for the missed appointment and to develop a plan to improve the client’s/family’s attendance at scheduled appointments.
  • If cancellations or no-shows meet the thresholds described above, subsequent appointments will be either made during off-peak hours or on a same day call-ahead basis. Under this modified scheduling plan an appointment must be kept within 30 days to return to the regular scheduling plan.
  • If no sessions are kept/attended within 30 days, we will assume you are no longer interested in services, and we will move you to an inactive You can always recontact us when you are ready to resume and recommit to treatment.

Informed Telehealth Consent

Since early in 2020, C&A has been providing some of our traditional behavioral health services by telephone, computer, or other electronic devices (often called Telehealth).  While we believe that in most circumstances in-person and face-to-face services are the most effective, we recognize that for some clients Telehealth may be a preferred or convenient method of receiving services.

When Telehealth is appropriate, we are able to provide services to you on your home phone, cell phone, through FaceTime, or by using Zoom, Teams, or other similar services; let us know what works best for you and we will find the way that is comfortable for both of us.  C&A recommends using Teams, as our version is secure and HIPAA compliant.  Some communication methods are more secure than others, and we want you to be informed and know that confidentiality, your safety, and getting you the help you need will always be important to us.  To improve security, please do not use public or free wi-fi for video sessions.  It would be best to use a telephone call if only public wi-fi is available.  And please know that no recording is permitted during sessions, either by us or by you.

In addition to the convenience or health benefits of using Telehealth services, there may also be potential problems.  Internet and phone service may experience connectivity issues, and some electronic communications have the potential to be accessed by others. It is important that we are able to communicate with you if problems arise, and we would like your permission to contact you by phone, text, and email.  As much as possible, it is important to be in a quiet, private space during sessions, without distractions, and where others cannot hear you.    It is important to be on time for your appointments, and to call or email your provider if you need to cancel or reschedule.

At the beginning of each session, we will verify your current location and who to contact in the event of an emergency.  We will get parent permission to hold sessions by Telehealth for all minors.  If your connection is lost during a session, your provider will try to recontact you.  If your provider is concerned for your safety during or after a session, s/he may call Mobile Crisis or the police.

Medicaid and many major insurers are covering Telehealth services, but you are encouraged to contact our billing department or your insurance carrier to confirm coverage if you have any questions.

 In making application for services for myself or the above-named minor, I hereby authorize Child and Adolescent Behavioral Health, through any if its components, to provide evaluation and/or treatment services as are deemed necessary.  I am aware that I may contact Child and Adolescent Behavioral Health (330-454-7917) and/or  Coleman Crisis Services (330-452-6000) should an emergency arise.

In the event of an emergency, information will be provided to Coleman Crisis Services, or the hospital service provider, or any other emergency treatment provider.