Larch Team Form Submissions Type of FormAdmin Hour SubmissionAlternative Stipend SelectionAssessmentsCEU ReimbursementConsult AttendanceExtended Session SubmissionMileage ReimbursementPayroll AdjustmentsReimbursement Request (Expense)Time Off/PTO Fund RequestWebsite Update Request Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Pay Period Month*SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberPay Period Range*Select1 - 1516 - end of monthAdmin Hours Hours Hours Described Date Actions Edit Delete There are no Hours. Add Hours Maximum number of hours reached. ***This form is for Admin use only***Submission Date* MM slash DD slash YYYY Consult Team*SelectNorth BendDuvallAll TeamHired Member Attendance *Intern Attendance* Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Date of Purchase* MM slash DD slash YYYY Date of Training* MM slash DD slash YYYY Please describe the purpose of the training and how it will impact your work with Larch and/or how it will help you meet your CE license requirements.Training 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. Cost of Purchase*Upload Receipt*Max. file size: 32 MB. Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Pay Period Month*SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberPay Period Range*Select1 - 1516 - end of monthClient Initials* Date* MM slash DD slash YYYY Additional Amount Billed* Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Trip Described* Date* MM slash DD slash YYYY Mileage*Cost/Mile: $0.60 Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Reimbursement Type:SelectCEU (Continued Education)ExpensesDate of Purchase* MM slash DD slash YYYY Reimbursement Description* Cost of Purchase*Upload Receipt*Max. file size: 32 MB. Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Type of Assessment:*SelectConnors 3 ADHD Assessment (6-18)CAARS Adult ADHD AssessmentHiddenConnors 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* MM slash DD slash YYYY Report Report Type Name Email Actions Edit Delete There are no Reports. Add Report Maximum number of reports reached. HiddenCAARS Adult ADHD AssessmentThe 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*SelectMaleFemaleOtherDate of Birth* MM slash DD slash YYYY Email Address* Member Name* First Last Member Email* Who is Completing this Submission?*SelectSelf (Team Member)AdministrationAdministration Name* Administration Email* Submission Date* MM slash DD slash YYYY Pay Period Month*SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberPay Period Range*Select1 - 1516 - end of monthClient Name* Note: Put NA if not related to a clientDate of Service* MM slash DD slash YYYY Put NA if not related to a DOSHiddenAdjustments Described*Adjustments Described* Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Direct Deposits can take up to 10 days to update. Please note this when you are making your selectionSelect 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 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* Member Name* First Last Work Email* In order to utilize the Alternative Stipend, you must have denied insurance coverage with Larch's group Medical InsuranceSubmission Date* MM slash DD slash YYYY Selection Type?*Initial SelectionUpdating SelectionStipend Funds can only be updated during our open Larch's open enrollment (Currently December)Select A Stipend* Child Care Stipend CEU Fund Expansion Stipend Health/Self-Care Stipend Read Description Below1) 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 paychecks2) CEU Fund Expansion The full amount will be applied towards your CEU Fund account each month, and follow the same process outlined for the standard CEU Stipend3) 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. What Site?*ClinicRSD Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Each RSD Clinician has an equal amount of PTO and Sick Time per year to the number of days a week they work. For example, if you work two days a week, you have two PTO days a school year, and 2 sick days a school year. Sick days are reserved for when you are sick and cannot be submitted in advanced. Sick days can be used for some family emergencies. All time off must be approved. Dates Requesting Off (Multiple Entries Possible) Date Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Member Name* First Last Email* Submission Date* MM slash DD slash YYYY Pay Period Month*SelectJanFebMarAprMayJunJulAugSepOctNovDecPay Period Range*Select121 = 1st-15th 2= 16th- End of MonthOnly put dates within the pay period you selected. If you have dates to request off outside the selected pay period, submit an additional formDates Requesting Off Date Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Applying for PTO?*SelectYesNo# of PTO Hours*HiddenWork Dates Requesting Off/Applying for PTO Funds
