School-Based Therapy Services
In order to start school-based therapy services with The Caring Collective LLC, please fill out Client Information, Care Planning, and Release of Information.
Client Information
Client's Legal Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Client's Preferred Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Phone Number
*
Please enter a valid phone number where you can be reached in order to set up services.
Format: (000) 000-0000.
Client's Sex Assigned at Birth
Please Select
Male
Female
Unknown
Client's Gender Identity
Please Select
Male
Female
Non-binary
Trans Woman
Trans Man
Prefer not to say
Other
Client's Spoken Language(s)
Insurance Coverage
*
Please Select
Yes I have insurance and plan to use it
I do not wish to use my insurance and will be responsible for all charges myself
No I do not have insurance
Unknown if client has current coverage
Insurance Information
Upload the Front of Your Insurance Card
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Choose a file
Cancel
of
Upload the Back of Your Insurance Card
Browse Files
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Choose a file
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of
Legal Guardian's Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Legal Guardian's Relationship to Client
*
Examples: Mother, Father, CPS Caseworker, Stepparent with Medical Rights
Legal Guardian's Phone Number
*
Format: (000) 000-0000.
Legal Guardian's Email
*
example@example.com
**CHILDREN IN ALTERNATIVE PLACEMENT or CHILDREN OF DIVORCED/LEGALLY SEPARATED PARENTS
Copy of legal guardianship paperwork such as current custody agreement, court orders, signed letter from a judge, Medical Power of Attorney, and/or Individual Child Care Agreement (ICCA) must be received at the time of intake otherwise follow up appointment cannot be scheduled until it is received, as instructed by the Licensing State Board.
Care Planning
Therapy Setting Preference
*
Margaretta Elementary School Building
Margaretta Middle/High School Building
Townsend Community School
Virtual/Telehealth Option
Who referred the client or how did you hear about our services?
Reason for Services
*
In-Person Safety Screening: Please indicate if any of the following apply to the client. Your responses are confidential and used solely to support safety and care planning needs.
Client has had cold and/or flu-like symptoms within the last seven days
Client has been to the Emergency Room (ER) for physical or mental health care within the last 30 days
Client has current suicidal or homicidal thoughts or has engaged in self-harming behaviors; or client has had them within the last 30 days
Noticed bed bugs, fleas, lice, or other pests in the home or on personal belongings of the client within the last 30 days
Has the client had close contact with someone who has been treated for bed bugs, lice, or other pests within the last 30 days
Does the client have any current legal situations or within the last 30 days involving violence (e.g., assault, domestic violence, protective orders)
Are there any current criminal charges related to weapons, violence, or harm to others that has occurred in the past 30 days involving the client
Client is currently involved in an active domestic violence situation where there is verbal, emotional, physical, sexual or financial abuse or misuse towards them
Client is using power and control tactics or manipulation over another person
Other Significant Information
Please provide any additional information that you feel is important to share prior to meeting.
Questions
Are there any questions you might have about the process or regarding treatment?
Release of Information
By signing this part of the form, the Legal Guardian is authorizing The Caring Collective LLC and Selected School District to be able to exchange information, giving Consent to start coordinating services to provide therapy and counseling school-based services to the Client.
Client's Legal Guardian Must Fill Out
Authorization to Use and Disclose Confidential Protected Health Information [3793:2-1-06(H)]. This form cannot be used for the re-release of confidential information provided to The Caring Collective LLC by other individuals or agencies. Such requests should be referred to the original individual or agency.
Client's Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Select School System
*
Please Select
Margaretta Local School District: 5906 W Bogart Road, Castalia, Ohio 44824; Phone: 567-228-7174
Townsend Community School: 207 Lowell St, Castalia, Ohio 44824; Phone: 419-684-5402
Purpose of Disclosure
*
Referral and Eligibility Information
Scheduling/Coordinating Appointments
Coordinating On-Going Treatment Efforts
Safety Planning
504 Plan/IEP Coordination
Other
Information to be Disclosed: Note mandatory options marked with an asterisk
*
Demographic and Contact Information*
School Schedules/Attendance*
Minimal FERPA/Educational Records, Deemed Necessary for On-Site Services*
Evaluation Team Report (ETR)/Multi-Factored Evaluation (MFE)
Individualized Education Program (IEP)/504Plan
Diagnosis
Treatment Recommendations
Crisis/Risk Assessment
Psychiatric/Psychological Evaluation
Progress/Participation in Treatment
Other
Legal Guardian's Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: