Intake Forms Download Page

Comments or Questions? >  Please e-mail them to us.

Please complete the following forms and bring them to your first appointment.
Client Information Form 
Each person coming to therapy is to complete one of these forms.
Fee Agreement (two copies – one for you and one for Samaritan) 
Fees may be set by phone beforehand with your therapist or at the first session. Each person coming to therapy is to read and sign this form at the bottom of both copies.
Note: If you do not plan to use insurance, each person is to write his/her initials in the space provided on both copies.  Your therapist will sign and return a copy to you. 
Disclosure Statement (two copies – one for you and one for Samaritan)
The disclosure statement for your therapist may be downloaded on the Therapist Disclosure Statement Forms Page >
Please read this form, print your name in the space for ‘client name,’ then sign and date it as indicated on the last page. Each person coming to therapy is to read and double-sign this. Repeat this for the second copy. Your therapist will sign and return a copy to you.
Notice of Privacy Practices (one copy for you)  Please read this and keep it with your records.