* Required fields
Client's First Name *
Client's Last Name *
Date of Birth *
Age *
Parent or Guardian’s Name (if under 18)
Address *
City *
State *
Zip *
County *
Primary Phone # *
Can we leave a message? *
Secondary Phone #
Can we leave a message?
Email address *
I would like to be placed on the Samaritan Counseling Center mailing list to receive newsletters and other center information.
Marital StatusSMDW
Gender
Employer/School
Occupation/Year in School *
Race/Ethnicity *—Please choose an option—White/CaucasianAfrican AmericanNative American/Alaska NativeAsian AmericanNative Hawaiian/OtherPacific IslanderHispanic or Latino OriginOther
Race if other
Religious Affiliation, if any
Importance to you
Place of Worship
Name *
Relationship *
The Samaritan Counseling Center is a non-profit organization and is able to provide subsidized counseling, as needed, due to the contributions of our many funders to our Jeremiah 29:11 Fund. If one requires assistance funding and in order to secure funding, it is often necessary to provide aggregate household income data for our client base, which illustrates our financial need. This figure is to include all sources of income -- i.e. salary, child support, maintenance, investment income, housing allowances. Please check the appropriate range for your gross family income and the number of members living in or financially dependent on your household. Information provided to funders is only given in aggregate form and individual client information is not released.
Number in Household *
Less than $25,999$26,000-$29,999$30,000-$39,999$40,000-$49,999$50,000-$59,999$60,000-$69,999$70,000-$79,999$80,000-$89,999$90,000-$99,999Over $100,000
Requested Services *Individual TherapyCouples TherapyFamily Therapy Please note that Samaritan does not offer psychiatric medication administration, medication management, or ADHD testing.
Referred By?
or
The Beacon Center
If not referred, how did you hear about us?
Clinician Preference (currently accepting new patients)NO PREFERENCESaralu P. BelkoferAvery BerryAllena BurbageKay CannadyMary ClarkAmy CorwinDaryl K. HamblinLennie HowardGeorge IshmanZandra Rudolph-Heard
Counseling Setting Preference *In-PersonTelehealthNo Preference
Are you capable of climbing stairs? *YesNo
Please briefly explain what has caused you to seek counseling *
Secondary Client’s Name (as needed)
DOB
Age
Email
Race/Ethnicity —Please choose an option—White/CaucasianAfrican AmericanNative American/Alaska NativeAsian AmericanNative Hawaiian/OtherPacific IslanderHispanic or Latino OriginOther
Do you require financial assistance in order to receive counseling services? If yes, proof of income will be required.YesNo
Will you be using insurance?YesNo
Primary Insurance *
Phone *
Policy Holder *
DOB *
ID# *
Group *
Employer *
Will you be using secondary insurance?YesNo
Secondary Insurance *
I would like to use Employee Assistance Program (EAP) benefit if I am eligibleYesNo
Employee Name/Member
Employer
EAP Provider
Client Relationship to Employee/Member:
**Authorization from EAP Provider is needed prior to intake session. If I fail to obtain authorization, I am responsible for payment to The Samaritan Counseling Center for the denied session.
