Client Forms

Client Forms

Thank you for choosing Samaritan Counseling Center. If you are coming for the first time or after a long absence, please print the applicable forms and bring them to your first appointment.


Client Registration Form: All new clients and clients returning after more than six months since last session must complete this form. Please print and bring to your first appointment.

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Counseling and Fee Agreement Form: This is for your information. You don’t need to bring it to your appointment, but be aware that by signing the Client Registration and Insurance Agreement forms, you are agreeing to the policies detailed here.

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Insurance Agreement Form: If you would like us to bill your insurance company for services, please print this form. Bring the completed form and your insurance card to your first session.

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Authorization to Disclose Information Form: This forms grants us permission to disclose information regarding your appointment to your primary care physician or referring professional.

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Authorization to Release Appointment and Billing Information Form: If you would like someone close to you (such as a spouse, parent, etc.) to be able to call and schedule or cancel appointments on your behalf or talk with us concerning billing matters, please print and complete this form.

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