Here are other forms Samaritan or your therapist may ask you to fill out.
To download the therapist’s standard intake forms, including their disclosure statement, visit Find a Therapist and click on the therapist’s name. Their standard forms are found on their profile page.

Samaritan Standard Forms and Information

This is our standard packet of information, including the forms required for any new client. Download the packet for the type of therapist you’re visiting before your first appointment. If you don’t know the correct set of forms to use, the correct forms for each therapist, along with their unique and required Disclosure Form, are available on the therapist’s profile page, found from the list on the Find a Therapist page.

Masters Level forms and information
This is the most commonly used set of forms for our therapists.

Psychologist Level forms and information
For any therapist with a psychology degree, most commonly indicated by a “Psy.D.” suffix after their name.

Low-Fee Clinic, Extern forms and information
These forms are for externs providing therapy as part of our Low-Fee Clinic. Visit the Low-Fee Clinic page for more information.

Other Forms

Authorization to Exchange Information
Sometimes in the course of therapy, your therapist may want to consult with your other providers, such as medical doctors, or other therapists counseling you or your family. If these circumstances arise, your therapist will discuss it with you and ask you to give your permission, using this form.

Questions to Ask Your Insurance Provider
Here is a list of questions you might ask your health care provider in order to better understand the benefit available to you for services at Samaritan Center.

Teletherapy – Complete Set of Forms
The 4 forms in the set apply to initiating Teletherapy, or online therapy.

• Informed Consent Teletherapy Addendum
  Explanation of teletherapy terms and conditions to allow you to make an informed consent.
• Teletherapy Intake Addendum
  Important information to assess crisis level.
• Teletherapy Emergency Plan
  Information to allow your therapist to respond to a medical or psychiatric emergency.
• Authorization to Exchange Information (same form described separately above)

Teletherapy – Complete Set of Forms for Couples

• As above, slightly amended for couples

Teletherapy – Complete Set of Forms for Families

• As above, slightly expanded for families