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Marriage/Couple Counseling Client Forms


All clients complete steps 1 through 5.  

1. Print the Client Information Form >  (there will be two forms, one for each person)

2. Print the Client Referral Information Form >

3. Print the Master's Level Fee Agreement >  Psychologist's Level Fee Agreement > (there will be one copy for you, one for your therapist)

4. Print your Therapist' Disclosure StatementTherapists' Disclosure Statement >  (there will be one copy for you, one for your therapist)

5. Sign each copy of the Disclosure Statement, indicating that you have read Samaritan's Privacy Practices >

6. If you plan to use insurance, go to:  Insurance Information Form >  

7.  If you want your therapist to request information from a previous therapist, print and complete the following form:  Consent for Exchange of Information >

8.  If you wish to communicate with your therapist and/or administrative staff via email, print and complete the following form:  Informed Consent for the Use of Email >

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