Larch Team Form Submissions

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Member Name*

First Last

Work Email*

Type of Professional Development*

Submission Date*

Date of Purchase*

Date Training Completed/Test Passed*

CE Hours and Type?*

Please describe the amount of hours, and what category the apply to (General, Law and Ethics, Suicide, Professional Boundaries, Equity, etc.)

Cost of Purchase*

Professional Development Description*

You may request the full amount of the training. You will get paid out what you have already accumulated to date, and if the training was more than you have already accumulated, you will receive a monthly reimbursement until the balance is paid in full, or your annual allotment is met. You can ask the admin what your current available funds are, and also what your total allotment is for the full year is.

Upload Receipt

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Upload Additional Documents (optional)

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Member Name*

First Last

Email*

Submission Date*

Pay Period Month*

Pay Period Range*

Client Initials*

Date*

Additional Amount Billed*

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Name

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Member Name*

First Last

Email*

Submission Date*

Trip Described*

Date*

Mileage*

Cost/Mile:
$0.60

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Phone

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Member Name*

First Last

Email*

Submission Date*

Date of Purchase*

Reimbursement Description*

Cost of Purchase(s) -Total for multiple Receipts*

Upload Receipt(s)*

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Comments

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Member Name*

First Last

Email*

Submission Date*

Type of Assessment:*

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Connors 3 ADHD Assessment (6-18)

This Connors 3 Assessment is for ages 6-18, with the self-report being administered to children 8-18. In order to gather a range of data points, this report is to be provided to the client, two parents/guardians, and at least one teacher. The teacher should be for a subject that requires some level of focus. Avoid subjects such as PE, Art, or another engaging elective. Two teacher would provide a wider range of data points. NOTE: You must first get permission from the teachers, parents, and client before you submit for this assessment. These assessments are also for conversation, and are not designed to be used as a test that would be administered by a psychologist. Any recommendations about medication should be left to the prescriber, but this may help us make the referral to the provider. These test cost us money, which we are happy to spend, but we do not administer them to everyone for that reason. If we notice things that point towards ADD, then we can use this as a tool.

Client Name*

First Last

Client Date Of Birth*

Report

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CAARS Adult ADHD Assessment

The CAARS™ measure the presence and severity of ADHD symptoms in adults. Thes assessments are also for conversation, and are not designed to be used as a test that would be administered by a psychologist. Any recommendations about medication should be left to the prescriber, but this may help us make the referral to the provider. These test coast us money, which we are happy to spend, but we do not administer them to everyone for that reason. If we notice things that point towards ADHD, then we can use this as a tool. Make sure the person you are administering it to knows it is coming.

Client Name*

First Last

Gender*

Date of Birth*

Email Address*

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Company

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Member Name*

First Last

Email*

Submission Date*

Direct Deposits can take up to 10 days to update. Please note this when you are making your selection

Select One

My current account is still active, but I would like to update it to a new account

Please freeze my direct deposits, and I would like to update to a new account

Please freeze my direct deposits until I get my account issues resolved

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Phone

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Please perform your own spell check before submitting to ensure that there are no errors in your updates. Also, include the full description for each of the sections you are updated. For example, do not simply write “Can you add “I like swimming” to my about me section. Instead, add the complete text, which may mean copy and pasting what you currently have active on the website.

If you are not updating a field, put “NA”.

Member Name*

First Last

Credential*

Email*

A Little About Me*

My Hobbies*

Education/Experience*

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Comments

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Member Name*

First Last

Work Email*

In order to utilize the Alternative Stipend, you must have denied insurance coverage with Larch's group Medical Insurance

Submission Date*

Selection Type?*

Stipend Funds can only be updated during our open Larch's open enrollment (Currently December)

Select A Stipend*

Child Care Stipend

Professional Development Fund Expansion Stipend

Health/Self-Care Stipend

Read Description Below

1) Child Care Costs The child card stipend is designed to help support you in any child care cost that are accumulated over the year. Because child care needs can fluctuate, if you apply for this stipend, you will receive the full amount each month, split across paychecks

2) Professional Development Fund Expansion The full amount will be applied towards your professional development Fund account each month, and follow the same process outlined for the standard professional Development Stipend

3) Health/Self-Care Stipend This stipend is designed to allow clinicians to benefit from the funds if they cannot utilize one of the first two possibly tax-exempt Stipends. Depending on how the funds are used for the Health/Self-Care Stipend, it may be considered taxable income and you may have a tax responsibility for the funds at tax filing. This stipend will be deposited into your bank account each pay cycle, and can be used for anything a Employee deems a Health or Self-Care cost, including, but not limited to Therapy Cost, Ski-Passes, Spa Days, Fancy Dinner, Traveling, or a Paddle Board.

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URL

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Member Name*

First Last

Email (Larch Email)*

Before submitting, please consult with your supervisor about your planned time off. Mainly to consider your hours and consistency for clients. You can view the polices around time off as part of your discussion.

Submission Date*

What are your plans for your clients?*

Purpose of Time Off?*

Dates Off/Requesting Off

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Comments

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Member Name*

First Last

Email (Larch Email)*

Submission Date*

Pay Period Month*

Pay Period Range*

1 = 1st-15th 2= 16th- End of Month

Type of Submission*

What are your plans for your clients?*

Purpose of Time Off?*

Only put dates within the pay period you selected. If you have dates to request off outside the selected pay period, submit an additional form.

Applying for PTO?*

# of PTO Hours*

Dates Off/Requesting Off

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Reason for Requesting Caseload Dip PTO

Please write reason for requesting PTO Funds. Reasons include client cancelations for sickness, holidays, or a low season for intakes

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Work Dates Requesting Off/Applying for PTO Funds