Samaritan Health and Living Center

Therapy for Individuals, Couples, & Families

Intake Forms

Below you will find a number of useful forms you can download, print out, and fill out to bring to your first appointment.

ADULTS
(18+)

Consent to Treat

Fee Assistance App

Initial Questionaire

Permission to Share

Release of Information

HIPAA Privacy Practices

HIPAA Receipt of Policy

Statement of Agreement

Cross-Cutting Measure

Child in Waiting Room Policy

Cr. Card Authorization

Consent to Zoom Teletherapy

TEEN
(13 - 17)

Consent to Treat

Fee Assistance App

Initial Questionaire

Permission to Share

Release of Information

HIPAA Privacy Practices

HIPAA Receipt of Policy

Statement of Agreement

Cross-Cutting Measure

Waiting Room & Therapy Policy

Cr. Card Authorization

Consent to Zoom Teletherapy

CHILDREN
(12 and younger)

Consent to Treat

Fee Assistance App

Initial Questionaire

Permission to Share

Release of Information

HIPAA Privacy Practices

HIPAA Receipt of Policy

Statement of Agreement

Cross-Cutting Measure

Waiting Room & Therapy Policy

Cr. Card Authorization

Consent to Zoom Teletherapy