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Individual Counseling New Client Forms

 

All Clients: Complete steps 1 through 5.   

1.  Print the Client Information Form >   

2.  Print the Client Referral Information Form >

3.  Print the Master's Level Fee Agreement >  or Psychologist Level Fee Agreement > 
(There will be one for you, one for your therapist.)

4.  Print the Therapist's Disclosure Statement > 
(There will be one for you, one for your therapist.)

5.  Sign each copy of the Disclosure Form indicating that you have read Samaritan's Privacy Practices > 

6.  If you plan to to use insurance, go to: Insurance Information Forms >

7.  If you want your therapist to request information from a previous therapist, print the following form: Consent for Exchange of Information > 

8.  If you wish to communicate with your therapist and/or administrative staff via email, print the following form:  Informed Consent for the Use of Email >

 

 

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