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Family Counseling New Client Forms


All clients complete steps 1 through 4.  

1. Print a Client Information Form for each person coming to therapy: Client Information Form >   (each person completes one of this form)

2. Print the Fee Agreement: Master's Level Fee Agreement >  Psychologist's Level Fee Agreement > (there will be one copy for you, one for your therapist)

3. Print your therapist's Disclosure Statement: Therapists' Disclosure Statement Page >  (there will be two copies; each family member signs both copies)

4. Sign each copy of the Disclosure Statement indicating that you have read Samaritan's Privacy Practices >   (each family member signs)

5. If you plan to use insurance, go to: Insurance Information Form > 

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

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

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