School-Based Therapy Services
In order to start school-based therapy services with The Caring Collective LLC, please fill out Client Information & Care Planning Form, Release of Information for the School (this form), Consent for Services, and Privacy Practices Acknowledgement. Client's Legal Guardian must fill this form out.
Release of Information
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 Legal 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 Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Legal Guardian's Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Should be Empty: