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Dragonfly Counseling Screening Form
Please complete this screening form. We do our best to get back to you within 48-72 hours of your submission, and this is pending reaching out to our clinicians regarding their fit with your needs. Thanks in advance for your patience while we customize your care.
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* Indicates required question
Name
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Your answer
Name of client and relation to you (if other than self)
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Your answer
Age of Client
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Your answer
Date of Birth (of prospective client)
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MM
/
DD
/
YYYY
Physical Address of Client (Please include City and State)
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Your answer
Which location are you wanting to be seen at (both offer in person and telehealth)
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Clarkston, WA
Mill Creek, WA
Telehealth Only
Would you be open to online (Telehealth) counseling?
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Yes
I would be willing try or consider telehealth
Not for me at all
Therapist Preference (Currently there is very limited availability, if any, with a female therapist)
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Male
Female
Doesn't Matter
What are you seeking support with? Please check all that reflect a primary therapy need for support. Under "other" please indicate anything else that would be helpful to know about you in considering a therapist match.
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Anxiety
Depression
Stress Management
Significant life changes/transitions
Grief/Loss/Bereavement
Obsessive-Compulsive Symptoms
Relationship Issues
Marriage/Couples Counseling
Domestic Violence - Past
Domestic Violence - Current
Childhood Sexual Abuse
Childhood Physical Abuse
Childhood Verbal Abuse
Childhood Trauma
Acute or Chronic Trauma
Post Traumatic Stress Disorder
Secondary Trauma
Caregiver Stress
School Issues
Panic Attacks
Identity Issues
Career Counseling
Personality Disorders
Criminal/Legal Issues
Chronic/Critical Illness
Self-Harming Behaviors
Need a Diagnostic Evaluation to Determine Diagnosis
Other:
Required
Anything else we should know? (Type 'no' if there is nothing else we should know)
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Your answer
Phone number
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Your answer
Email
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Your answer
Preferred method of contact
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Phone
Email
Text
Preferred Availability for Appointments (best days and times)
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Your answer
What insurance do you have? If your insurance is not listed, then we do not have a provider that accepts that insurance, but private pay is an option.
*We do offer limited sliding fee and pro bono slots, which is determined on a case-by-case basis.
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Blue Cross of Idaho
Premera
Blue Cross Blue Shield
Medicare
Other:
What is the ID number on your insurance card? (this is usually a few letters followed by numbers unless you have Medicaid or Medicare). Type "NA" if this does not apply.
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Your answer
Please note that we do not accept all insurances and not all of our clinicians accept insurance, but we will provide a superbill when requested for you to submit to insurance if needed. Please indicate below if private pay is an option(Please note that we accept FSA and HSA cards).
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Yes, Private pay is an option
No, Private pay is not an option
Required
We have very limited spots with our female providers, if there is not availability with a female - would you be willing to try a male therapist.
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Yes
No
If we have minimal spots with all providers, would you be willing to see a graduate student under the direct supervision of a licensed therapist on a sliding fee scale?
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Yes
No
If you want to be considered for a sliding fee or pro bono slot, please type in your household income below and how many people live in the home. Please explain why you wish to be considered for a sliding fee or pro bono slot so that our staff can make a decision. Type "NA" if this does not apply.
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Your answer
How did you hear about us? (please be specific if doctor, school counselor, provider, etc - we like to express our appreciation to referral sources!)
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Your answer
By checking the box below you understand due to circumstances such as limited availability, insurance, and or the reasons in which you are seeking services for, that this form is not a guarantee of services.
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I agree to the above statement
Required
Please acknowledge that you understand it could take up to 48 hours for us to see your form and process it. Our administrative staff is in the office Tuesday, Wednesday, and Thursday. Please wait 1 week before following up.
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I agree to the above statement
Required
Required Consent
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By submitting this form, you consent to your information being transmitted through the internet to our records. And like any other internet-based system, we do our best to protect your information.
Required
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