Larch Team Form Submissions Type of FormAdmin Hour SubmissionConsult AttendanceExtended Session SubmissionMileage ReimbursementReimbursement RequestTime Off/PTO Fund RequestAssessmentsPayroll AdjustmentsWebsite 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 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* What Site?*ClinicRSD Member Name* First Last Email* Submission Date* MM slash DD slash YYYY 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
