Partnership papers

Clarity, care, and consent—without a maze.

Print a new-client packet, or finish intake, consent, privacy, the family agreement, and attendance here. We can complete papers together. Missing papers should never keep you from showing up.

Every journey begins with hope.

Begin your journey

Why these papers exist

Each form has a human job.

They are not a test, and they are not a commitment to a weekly package you have not agreed to. They help R.O.S.E. begin with your story, your yes, and a clear way to protect reserved time.

New client packet

Print registration, case history, consent, HIPAA, release, attendance, financial policy, and emergency information in one handoff. Missing papers should never keep you from showing up.

Open the packet

Client Intake / Registration

Demographics, contact, physician, school or daycare, diagnoses, and the communication concerns that bring you here. Bring what you have.

Open intake

Pediatric case history

Birth, development, school, and how this child communicates now. Not an AAC evaluation.

Open pediatric history

Adult case history

When conversation changed, medical history, and what a kinder month would hold.

Open adult history

Consent for Evaluation & Treatment

A clear yes before evaluation or therapy begins. Nothing starts until you agree.

Open consent

HIPAA Privacy & Release

How privacy works, and who R.O.S.E. may speak with—school, physician, or EI—only when you authorize it.

Open privacy & release

Therapy Expectations & Family Agreement

The partnership promise: what R.O.S.E. holds, and what families hold, so the work can live at home. Brief consultation is $25 per 15 minutes. Consultation and IEP/educational support fees are not billable to health insurance.

Open family agreement

Cancellation & Attendance

How reserved time is protected. Late cancel and no-show fees are $25 unless waived, when less than 24-hour notice is given.

Open attendance policy

Financial policy

Consultation is $25 per 15 minutes. Late cancel is $25 unless waived. Therapy amounts are named before care begins. This is not a payment page.

Open financial policy

Teletherapy consent

A yes for video visits when teletherapy serves the plan. Same 24-hour cancellation courtesy.

Open teletherapy consent

Photo / video / recording

Clinical recordings, internal training, and a separate written yes before anything is used to market the practice.

Open recording consent

How to complete them

Together is always an option.

Print the new-client packet blank and hand it to a parent or caregiver, or complete a form in the browser, save a draft, print a PDF, or email a summary
Bring signed pages to the first visit, or mail them to P.O. Box 361, Blue Island, Illinois 60406
We can finish papers together on a call or at the first visit
Missing papers should never keep you from showing up
Prior reports, IEPs, and hospital notes are helpful when you have them—never required to call
This website does not scan or upload signed packets. Please do not email photos of signed papers

Open the form list Print the packet After the packet Start with intake First visit Someone you love Your hour More than one Finish them together

What this is not

Clear limits protect families.

These pages are not legal advice. Please review privacy and consent language with your own counsel as needed.
Evaluation, treatment notes, SOAP notes, plan of care, progress reports, goal data, home programs, and discharge papers are J'Vohnne's clinical templates. Families do not fill them out.
Papers are not a commitment to a weekly package you have not agreed to. Fees are named before evaluation or therapy begins. Consultation and IEP/educational support fees are private pay and are not billable to health insurance.
A signed release is required before R.O.S.E. shares progress with a school, physician, or EI team. IEP meeting participation is a separately billable professional service.

Notice of privacy practices Records & sharing

A conversation is enough

Call first if the papers feel heavy.

You do not need a referral to start. You do not need every prior report. Fees are named before evaluation or therapy begins.

Call 773-457-1204 Start here The first conversation The wait After evaluation Request an appointment

Every bloom begins with R.O.S.E.