Session Scheduling

This is a request to schedule a future appointment with the Samaritan Counseling Center for NEW CLIENTS or CLIENTS WHO HAVE NOT BEEN SEEN IN THE PREVIOUS 6 MONTHS. (Existing clients who have been seen within the last 6 months should call 334-262-7787 to schedule.)

Our highly trained and licensed therapists can help you gain perspective, as well as provide professional support and guidance to help you navigate through life’s challenges. Once you complete this form, we will contact you within three business days to schedule your appointment.

    Personal Information
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    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.


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    Please list any additional people who will be attending the counseling session
    Client Assistance/Insurance
    Employee Assistance Program (EAP)