These adobe PDF forms are NOT SUBMITTED online, but they are accessed online.  You should not assume that any of the information you enter on these forms is secure, confidential or private — because these forms are not secure and they are not private. 

Want more security than the PDF?

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—ACCESS OUR ONLINE SECURE AREA INSTEAD—

REGISTER NOW TO ACCESS THE SECURE CLIENT AREA

When you elect to leave this “FORMS” area of the TalkifUwant website, and instead register, your information becomes secure, encrypted, and stored.  You’ll also be able to schedule and confirm your appointment after registering! Plus, all health information, demographics, family information, insurance information and even an optional diary (for you only or there’s one to share) will be stored and accessed during your appointment...there’s no printing, no file saving, and nothing to mail or bring into the office! 

Learn more about the client secure area by clicking here.

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If you wish prefer to use the adobe PDF forms found on this page (and not register as noted above), online users here are encouraged to open a new tab in Internet Explorer 8 (or later) and choose the “InPrivate” browsing feature BEFORE USING ANY OF THESE PDF FORMS.  After you have opened a new tab, and after you have selected “InPrivate” browsing, copy and paste the URL from this web page into the “InPrivate” browser.  You will return to this page (and the URL will show “INPRIVATE”).  For more information about “InPrivate” browsing users may also want to read the “Learn more about tabs and tab shortcuts, Accelerators, and InPrivate Browsing” link that will appear on the bottom of the new “InPrivate” window. 

USERS WHO UTILIZE THESE ONLINE FORMS ASSUME ALL RISKS IN DOING SO, SIMPLY BECAUSE CONFIDENTIALITY CANNOT BE ENSURED BY LAROSE.  USERS WHO SAVE COMPLETED FORMS ONTO A COMPUTER SHOULD KNOW THAT BY SAVING THE FILE TO A COMPUTER, YOU ASSUME ALL RESPONSIBILITY FOR THE INFORMATION YOU HAVE ENTERED ONTO THE FORM.

Users who are not comfortable with completing online forms and users who do not fully understand what information is accessible by others on the web (even for forms that are not saved or submitted) may feel more comfortable by opening and printing the appropriate form; by opening and printing the form, you will have a hard copy form that you can complete by hand.  After you print and complete the form by hand, you can then mail or hand deliver the form yourself.

All “FORMS” users should download the latest version of Adobe’s free Acrobat Reader® to view, read, print, save, or otherwise access the forms  that are available here.  When the selected form opens, please check the “highlight required fields” box (which will appear in the top right hand side of your screen).     

You may choose to “PRINT & SAVE” the forms as you complete them (there will be a button on each form); you may also skip the save and go instead to print.  When the PRINT & SAVE dialogue box opens you can choose to save the file after you complete the forms, or you can hit “cancel” when prompted to save (choose “Cancel” if you DO NOT WANT TO SAVE the form for privacy reasons) and the Print dialogue box will automatically open. 

PRIVATE PRACTICE / OFFICE BASED FORMS

In Office Minors—Parental Consent Form

Used when initiating counseling services for minors at the office of LaRose

Employee Assistance / Mandated Counseling /

and full Agreement Terms

Used when initiating professional services at the office of LaRose

In-Take Checklist and Billing & Insurance Authorization

Used by everyone who is seen for counseling services

In Office Intake / Complaint Form

Used by everyone when initiating counseling services at the office of LaRose

Consent to Obtain and Release Information—Simple Form

Used by anyone seen at the office of LaRose, with a history of other providers

Credit Card Authorization Form

Used to authorize credit card payments to LaRose

Records Request, UA Authorization & Referral Form

Therapy Note / Progress Notes — Office Sessions

ONSITE CLINICAL PROVIDER FORMS

School Therapy Note & Weekly Progress Report

(with provider progress note & billing record)

for clinical professionals who currently contract with LaRose

Student In-Take & Screening

(in-school provider screening document)

for professionals who currently contract with LaRose

Student Exit Interview Form

(in-school provider program evaluation document)

for professionals who currently contract with LaRose (for use at end of year)

ONSITE SCHOOL COUNSELING FORMS

School Counseling Permission Slip

(in school permission slip document)

for use (download, print, email) by subcontract clinicians contracted with LaRose

School Counseling Referral Slip

(in school referral document)

for use (download, print, email) by subcontract clinicians contracted with LaRose

Evaluation Forms for Teachers & Administration

Evaluation of Counseling Program

(open access for school personnel to complete; for use at end of school year)           

PROGRAM EVALUATION & FEEDBACK FORMS

Parent Evaluation & Feedback Form

Child Evaluation & Feedback Form