SPT Initial Screening Form

  • Initial Screening Form

  • Current Openings: (last updated 2/24/2026 at 11:40am)

    Mara Mulcahy:

    • Thursday 1:30pm virtual (for older child/teen or adult)
    • Thursday 2:30pm virtual (for older child/teen or adult)

     

    NOTE: These are the only times we have available at this time. We do not keep a waitlist and openings are offered to several families on a first come, first serve basis.

  • Please submit only ONE child per form. If you are submitting for more than one child (e.g. a sibling), please submit another form per additional child.

    Our general practice is that clinicians only see one child per clinician in session, and siblings will see different therapists.

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  • Format: (000) 000-0000.

  • By submitting, you agree to receive text messages at the provided number from Seattle Play Therapy, PLLC. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT of receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.

  • Client Information

  • ** Privacy Notice **

    Please note that the information you provide here becomes part of your official medical record as soon as you become a client. If you would feel more comfortable sharing certain information with us verbally, please let us know.

    This form is reviewed by a mandated reporter for child abuse or abuse of a vulnerable adult. For more information about mandatory reporting for child abuse, please visit the website for WA State Department of Child, Youth and Families.

  • Format: (000) 000-0000.

  • 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. 

  • Payment Information

  • Please refer to our fee information here: https://seattleplaytherapy.com/fees

  • Intern therapist services are offered on a reduced cash/private pay rate and is not reimbursable by insurance. 

  • *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 HMO/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.

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    • 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.

    • Rows

    • Parent Support Services

    • 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. 

    • COVID-19 Screening for In-Person Therapy Start 

    • 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.

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