SPT Initial Screening Form

Initial Screening Form
Full Name*

First NameLast Name
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Child is 13+*

YesNo
Childs Email:*
In the state of Washington, minors' consent to counseling services begins at the age of 13 years. An email for all 13+ clients is required to distribute consent forms for treatment.
Relationship to Child
Phone Number*
Do you provide consent to leave a voicemail or text message to the number listed?

YesNo
E-mail*
example@example.com
How did you hear about us?
Other
Do you have legal authority to consent to services for the child you are seeking services for? This is specifically for minors under the age of 13.

YesNo
Please tell us about your concerns.*
Do you have any legal involvement (e.g., custody, child protective services, etc.)? If yes, please describe.
Do you have two-households, for example, pending divorce/separation, divorced,, separated, nesting, two homes etc.? (For two household caregivers, we require consent from both parents. This question allows us to collect information for the other caregiver).*

YesNo
Secondary Caregiver/Guardian Name

First NameLast Name
Secondary Caregiver/Guardian Email
example@example.com
The initial email provided will be used to communicate client scheduling, paperwork, and additional information. If a secondary parent is present, please provide their email as it will be essential throughout the new client intake process.
Do you have any safety concerns (e.g., harm to self, others, abuse)? If yes, please describe.
Would you like your child to receive therapy IN PERSON?

YesNo
Would you be willing to see an intern therapist for private pay at a reduced rate? (Refer to our fee information here: https://seattleplaytherapy.com/fees)

YesNo
Would you like to use your insurance? Please note: To use your insurance we will need to provide your insurance company with a mental health diagnosis.

Yes, I will use insuranceNo, I will private pay*Depends*
*If you choose "No" or "Depends," in compliance with the Federal No Surprises Act, you will receive an automated email including a Good Faith Estimate of costs associated with Play Therapy.

Please Also Note: We are in network with Premera, Aetna and Kaiser PPO. We are Out-of Network with Regence, Anthem, United Health Care and Cigna

Many Blue Cross Blue Shield plans split reimbursement for services between Premera and Regence. Check with member services to confirm mental health services bill through Premera. If Mental Health Services bill through Regence: out of network benefits apply.

Insurance End
Scheduling availability: Our after school appointment times are EXTREMELY limited. Please note that we do not have a waitlist for afternoon appointments. Clients that start with a daytime appointment have first priority for moving into afternoon times before offering them to new clients.

I need an after school appointment time, and I understand that may impact my ability to be served.I can make a daytime (9am-3pm) appointment work.I am not sure about my schedule yet, please let me know the options.
Short-term therapy is a time limited program offered in the summer. You must commit to 6-12 sessions ahead of time, and then a short term treatment plan will be created for you. Are you interested in our Short Term program? (See the link below for more information)*

Yes - I will provide my availability belowNo thanks, I need long-term
Short-Term Play Therapy (STPT) program is not suitable for everyone. It's a great fit for kindergarten readiness, anxious children, toddler tantrums and much more! For more information, please click here.
To initiate a Short-Term Play Therapy you must commit to the scheduled dates/times prior to registration. To accommodate your schedule, please provide your availability. This will help us determine if we have a short-term opening that fits your needs.

To initiate a Short-Term Play Therapy you must commit to the scheduled dates/times prior to registration. To accommodate your schedule, please select ALL OF YOUR AVAILABILITY. This will help us determine if we have a short-term opening that fits your needs. *

	Mondays	Tuesdays	Wednesdays	Thursdays	Fridays
Week 1:July 29-Aug 2
Week 2: Aug 5-9
Week 3: Aug 12-16
Week 4: Aug 19-23
Week 5: Aug 19-23
Week 6: Aug 26-30
Week 7: Sept 2-6

Parent Support Services
If scheduling is a barrier, or you do not want your child to receive a mental health diagnosis, we also offer Parent Support and Coaching. These are caregiver-only sessions to problem solve specific issues and provide individualized parenting tools to implement immediately. This is a short-term parent support program and is NOT a healthcare service therefore is not reimbursable by insurance. Are you interested in Parent Support and Coaching? (See link/more info below).

YesNoPossibly
Parent Support and Coaching packages are individual pre-paid services on our website. Once you purchase a package, we will reach out to provide next steps. Appointments can generally be scheduled within one week. Click here to purchase or learn more. You are also welcome to schedule a 10-minute consultation with our Parent Support Specialist, Mara Mulcahy, prior to booking an appointment by emailing info@seattleplaytherapy.com.
Parent Groups: Are you interested in joining a parent support group?

YesNo
What topics would you like to address?

COVID-19 Screening for In-Person Therapy Start
How many people in your household?
How many people in your household ARE ELIGIBLE to receive the COVID-19 vaccine?
How many eligible people in your household HAVE RECEIVED the COVID-19 vaccine?
Is the child being seen for therapy fully vaccinated and boosted when eligible?
Policy for In-Person Therapy

I. Information

Given the current threat to your physical safety due to the possible transmission of COVID-19, Telehealth sessions are the safest option to receive therapy.

In choosing to meet in person with your provider, it is important that you are aware of the increased risk of contracting COVID-19 this poses, in addition to implications related to current laws for confidentiality.

II. Risks

Current research indicates that every face-to-face contact increases the risk of contracting and spreading the COVID-19 virus. Meeting indoors with limited airflow for a long period of time (such as a therapeutic hour) presents a high risk of transmitting the virus.

Some options that should decrease the risk are: meeting in a space with increased airflow, therapist and client maintaining at least 6 feet of distance, wearing masks that cover the nose and mouth, vaccination status and meeting outdoors (See Outdoor Therapy Consent form).

III. Confidentiality

Because of the current COVID-19 public health crisis, your name and contact information and dates of services may be required to be disclosed to public health officials for contact tracing thereby potentially disclosing confidential information.

IV. Safety Protocols

Strict safety protocols are in place both to protect you, SPT staff and the community.

I agree to comply with the safety protocols outlined by SPT and I understand that for the safety of myself and for others if I do not comply, in-person services may be revoked. I agree and understand:
- That all parties ages 5+ will be fully masked. (Exceptions include a condition that prevents the use of the mask.)
- Therapists, clients and family members will make reasonable efforts to physcially distance themselves when possible.
- Therapists, clients and family members who test positive for COVID-19 and have had an in-person ssession within 5 days will immediately inform their therapist, and vice versa.
- All therapists are fully vaccinated per Govenor Inslee's mandate for health care workers.
By attending in-person session, you agree that you are answering NO to the following COVID-19 screening questions:
- Are you or anyone in your household experiencing symptoms?
- Have you or anyone in your household been exposed to anyone who has tested positive for, or is believed to have, COVID-19?
I understand that I will not come to in-person session if the answer is “yes" to any of the above questions, and that I will be sent home and asked to reschedule should I answer "yes" to any of the COVID-19 screening questions.

If you (the client, parent guardian, or the child) are not able to adhere to the above safety measures, and/or you and your family members are eligible for the COVID-19 vaccine but have not received it, in-person sessions may not be a safe option for care and your provider will offer you a Telehealth appointment instead.

COVID-19 Screening for In-Person Therapy End
By providing my signature, I hereby agree that I have read and fully understand the above.
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Initial Screening Form

Parent Support Services