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Samaritan Health and Living Center

Therapy for Individuals, Couples, & Families

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  • Silent Samaritan 2023

574-262-3597

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

samaritan center

311 W. High Street
Elkhart, Indiana 46516
Telephone: 574-262-3597
Fax: 574-262-3599

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