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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

* Required fields

Client's Name(s) *

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 *

Race if other

Religious Affiliation, if any

Importance to you

Place of Worship

Emergency Contact

Name *

Relationship *

Primary Phone # *

Secondary Phone #

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

Kind of help requested *IndividualCoupleFamily

Referred By?

The Beacon Center

If not referred, how did you hear about us?

Counselor Preference (if applicable)

Counselor Gender Preference (if applicable)MaleFemaleNo Preference

Counseling Setting Preference *In-PersonTelehealthNo Preference

Are you capable of climbing stairs? *YesNo

Please briefly explain what has caused you to seek counseling *

Have you recently or are you currently experiencing thoughts of suicide or self-harm? *YesNo

Are you currently experiencing any abuse in your household? *YesNo

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

Secondary Client’s Name (as needed)

DOB

Age

Marital StatusSMDW

Gender

Race/Ethnicity *

Race if other

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

Primary Insurance

Phone

Policy Holder *

DOB *

ID# *

Group *

Employer

Will you be using secondary insurance?YesNo

Secondary Insurance

Phone

Policy Holder *

DOB *

ID# *

Group *

Employer

Employee Assistance Program (EAP)

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.

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