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Healing • Hope • Growth |
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Samaritan Health & Living Center |
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Fees & Forms |
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The Samaritan Center places an extremely high value on maintaining client confidentiality and strives to protect this privacy fully within the limits of the law. |
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The Samaritan Center sets fees according to the actual cost of delivering services. Our fees are among the lowest in the community. We assist clients in filing for health insurance benefits and may be able to reduce fees for clients who cannot afford the full cost of their counseling. We do not accept Medicare or Medicaid. |
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Did you know that you can also use your online bill pay option through your banking institution to send us your payments or donations? Contact the Financial Assistant with any questions. |
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Fee Assistance Form
If you feel that the full cost of sessions will be too much of a financial burden due to your situation, speak to your therapist about our Fee Adjustment Program. Your therapist will ask you to fill out this form and return it at your next appointment. |
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Intake Forms
Before your initial visit to the Samaritan Center, you will need to fill out several forms. Generally, we ask that you arrive approximately 30 minutes before your appointment in order to give you plenty of time to complete the necessary forms. However, if time is a factor, you can download these forms and complete them ahead of time. Each person participating in the sessions will need to have these forms filled out before the session. Parents/guardians will need to supply information for children under 18 years of age.
Initial Questionnaire — This form is a starting point for the therapist to get an idea of the issues that lead you to seek treatment.
Privacy Practices at the Samaritan Center—Please read the Notice of Privacy Practices at the Samaritan Center. You may print a copy for your records. You will need to sign the Receipt of the Samaritan Center’s Notice of Privacy Practices and bring this with you to your first appointment.
Permission to Share— We cannot give out any information about clients without prior written permission. This form will allow you to designate certain persons with whom we can speak, and to specify what kinds of information we can share with them. |
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Individual History
During your first session, your therapist will ask you to fill out a more in-depth form regarding your history and upbringing. This will help the therapist get a better understanding of you and your situation. Again, all persons involved in the counseling will be given this form to complete. |
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To contact us: |
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Please contact us if you wish to fill out your paperwork prior to your first session. The forms can be sent via email (in PDF format), standard mail, or fax. |
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Make a payment on your account online! |
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Need to make a payment on your account? |