These are other forms that Samaritan Center 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 individual forms are found on their profile page.

Agreement for Collateral Participant

Samaritan Standard Forms and Information
These are the forms required for a new client. Download and complete the packet for the therapist you are seeing before your first appointment. The correct forms for each therapist, along with their individual Disclosure Statement, can be found on their profile page.

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

Psychologist Level Forms and Information
These forms are for our therapists who have a psychology degree.

Other Forms
Authorization to Exchange Information
In the course of therapy, your therapist may want to consult with your other providers or your family.  Your therapist will discuss this with you and ask you to give your permission using this form.

Questions to Ask Your Insurance Provider
This can help you better understand the benefits available to you at Samaritan Center.

Teletherapy – Complete Set of Forms for Individuals
These four forms are required for beginning Teletherapy (virtual or on-line therapy).
1. Informed Consent Teletherapy Addendum (Explanation of terms and conditions of teletherapy)
2. Teletherapy Intake Addendum (Information to assess crisis level)
3. Teletherapy Emergency Plan (Allowing therapist to respond to a medical or psychiatric emergency)
4. Authorization to Exchange Information (Described above)

Teletherapy – Complete Set of Forms for Couples
Teletherapy – Complete Set of Forms for Families