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Private Practice & In Office Forms

EAP / Mandated / Agreement

Office In-Take & Complaints

Office Parental Consent

Onsite Provider Forms

School District Referrals

Forms Found On This Page —

Teacher Evaluations

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Provider Support in Digital Practice Setup

Forms can be completed in a public online format OR they can be completed in the HIPAA Compliant Secure Client Web Portal.  The adobe PDF forms (linked near the bottom of this page) are NOT SUBMITTED online, but they are accessed online, printed out, and brought to your appointment.  IT IS RECOMMENDED THAT YOU USE THE SECURE CLIENT AREA INSTEAD!   The secure area ensures confidentiality and all forms remain in the secure server (with nothing to print, nothing to save, and nothing to bring to your appointment).

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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 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

(this section is not for use by clients seen in the office)

 

 

*—NON-SECURE PAPER FORMS—*

* USE ONLY IF SECURE DIGITAL PLATFORM FOR PROVIDER SIDE ACCESS IS NOT AVAILABLE *

 

School Therapy Note & Weekly Progress Report

(with provider progress note & billing record) *

for clinical professionals who currently contract with LaRose

*THIS FORM IS NOW COMPLETED IN THE PROVIDER SIDE SECURE DIGITAL PLATFORM WHERE ALL CLIENT PROFILES ARE STORED*

 

Student In-Take & Screening

(in-school provider screening document) *

for professionals who currently contract with LaRose

*THIS FORM IS NOW COMPLETED IN THE PROVIDER SIDE SECURE DIGITAL PLATFORM WHERE ALL CLIENT PROFILES ARE STORED*

 

Student Exit Interview Form

(in-school provider program evaluation document) *

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

*THIS FORM IS NOW COMPLETED IN THE PROVIDER SIDE SECURE DIGITAL PLATFORM WHERE ALL CLIENT PROFILES ARE STORED*

 

What is the onsite client side access to secure services?

 

ONSITE SCHOOL COUNSELING FORMS FOR THE SCHOOL AND THE PARENT(S)

 

School Referral Form and Permission Slip (TCSD 12-13)

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

 

School Referral Form and Permission Slip (GCSB 12-13)

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

 

Evaluation Forms for Teachers & Administration

 

Evaluation of Counseling Program (all sites / all years)

(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