General Intake Form

    If you are in crisis, please do not wait for a response to this form. Call 911 for emergency services or go to your nearest hospital emergency room.

    You can also call or text 988 to connect with the 988 Suicide & Crisis Lifeline. The Lifeline provides 24-hour, confidential support to anyone in suicidal crisis or emotional distress. Support is also available via live chat. Para ayuda en español, llame al 988.
    Personal Information

    * Required fields

    I would like to be placed on the Samaritan Counseling Center mailing list to receive newsletters and other center information.

    Emergency Contact

    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.


    or

    Please list any additional people who will be attending the counseling session

    Client Assistance/Insurance

    Employee Assistance Program (EAP)