Parent or Guardian’s Name (if under 18)

Address *

Email address *

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.

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

If not referred, how did you hear about us?

Counseling Setting Preference *In-PersonTelehealthNo Preference

Are you capable of climbing stairs? *YesNo

Please briefly explain what has caused you to seek counseling *

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

Secondary Client’s Name (as needed)

Client Assistance/Insurance

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

Will you be using secondary insurance?YesNo

Employee Assistance Program (EAP)

I would like to use Employee Assistance Program (EAP) benefit if I am eligibleYesNo