PTC: Therapy Consultation Screening Form

  • PTC: Therapy Consultation Screening Form

  • Welcome! We understand that the process of finding the right support can be daunting and you may already have tried to get in touch with other practices and not gotten the help you were seeking.

    Our intention in creating this screening form is to get a sense of how we can support you and/or your family members from the start.

    PTC has in-person openings in both Frederick, MD and North Bethesda, MD, as well as virtual openings for clients located in Maryland, Virginia, DC, Delaware, South Carolina & PSYPACT® states.

    If you are only interested in TESTING, please DO NOT submit this form. Instead, email testing@playfultherapy.net to get connected to our Testing Intake Coordinator.

  • Individual therapy and group therapy are offered ONLY to clients who are physically located in Maryland, Virginia, DC, Delaware, South Carolina, or PSYPACT® states.

    This is because we are legally restricted to practicing ONLY where we are licensed or approved.

    If you are not in MD, VA, SC, DE, DC, or PSYPACT® states, we will not be able to provide psychotherapy only parenting/caregiver consultation.

  • Please note that as per MD, VA, SC, DE, DC, & PSYPACT®* states law (as well as in many other states), mental health professionals are mandated reporters. This means that we are required by law to make a report to the appropriate entity in the event that we know or suspect a child is experiencing abuse or neglect. If you include information on this form that leads us to have concerns for child abuse or neglect, we will report as mandated.

    IMPORTANT NOTE: These forms are not monitored daily and never reviewed outside of business hours. We may not see notes about safety concerns immediately. Please call 911 or proceed to the nearest emergency room if you or someone you are supporting is at risk of harm, or in case of another emergency.

  • Demographics

    Tell us more about yourself and who you are seeking support for.
  • Format: (000) 000-0000.
  • If we are able to provide the services you're seeking, when can we call you for your free 15 minute phone consultation? (If you would like to complete the consult via email, please select any time and check the box below to request an email consult)*
  • Please check any accommodations that could make this process more accessible for you. If the accommodations you need aren't listed, please email hello@playfultherapy.net
  • If we are able to provide the services you're seeking, when can we call you for your free 15 minute phone consultation? (If you would like to complete the consult via email, please select any time and check the box below to request an email consult)

  • Client Demographics

  • Who are you seeking virtual/telehealth services for?*

  • How can we help?

  • Which service(s) are you interested in?*
  • Reason(s) for seeking support? Check any/all that apply.*
  • What are your top goals for therapy or parenting support?*
  • What are you looking for in a therapist? Check all that apply!*
  • PTC requires that for ongoing individual therapy, sessions start off weekly with the potential to taper off to every other week once you/your child starts meeting your/their goals. Are you able to commit to weekly sessions at this time?*
  • For group therapy, sessions are typically held on a weekly basis and attendance at each session is expected in order to promote group cohesion and reach maximum benefit. Are you able to commit to group therapy sessions at this time?*

  • The Last Bit!

  • PTC is out of network with all insurance providers. Are you planning to submit documentation (superbills) to your insurance company to receive reimbursement?*
  • Here is a link to our page that details the financial investment involved in working with our therapists: playfultherapy.net/investment*
  • In addition to our licensed providers, PTC also has Clinical Interns and Doctoral Externs who are currently enrolled in counseling or psychology graduate programs and are under the direct supervision of Laura Morlok, LCPC, LPC, RPT-S or Dr. Jaclyn Halpern. Our Interns and Externs are able to offer services at a reduced rate. Please note they are only able to work with clients located in MD, DC, or VA.*
  • How did you hear about PTC?*
  • Would you like to be added to our email list to be kept informed about upcoming groups and other events?*

  • *PSYPACT® state support is only available with Dr. Jaclyn Halpern. PSYPACT® is an interstate compact which offers a voluntary expedited pathway for practice to qualified psychologists who wish to practice in multiple states. PSYPACT® is designed to facilitate the practice of telepsychology and the temporary in-person, face-to-face practice of psychology across state boundaries. In order to practice telepsychology in PSYPACT® states, psychologists licensed in PSYPACT® states only, can apply to the PSYPACT® Commission for an Authority to Practice Interjurisdictional Telepsychology (APIT). In order to conduct temporary practice in PSYPACT® states, psychologists licensed in PSYPACT® states only can apply to the PSYPACT® Commission for a Temporary Authorization to Practice (TAP). The PSYPACT® Commission is the governing body of PSYPACT® and is comprised of one representative from each PSYPACT® state. More information regarding PSYPACT® and its requirements can be found at www.psypact.org

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