Become a Client

Counseling Type(Required)

What kind of counseling are you interested in?

Personal Information

This field is hidden when viewing the form

Today's Date(Required)

Gender(Required)

Male

Female

Prefer not to answer

Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Insurance Information
Will you be using insurance?(Required)

Yes

No
Insurance Policy Holder Name(Required)
First Last
Policy Holder's Address(Required)
Street Address Address Line 2 City State ZIP Code

Policy Holder's Date of Birth(Required)
MM slash DD slash YYYY

Relationship(Required)
Insurance Carrier(Required)
Policy ID(Required)

Counseling History
Are you presently seeing another counselor?(Required)

Yes

No
Have you had previous counseling or psychotherapy?(Required)

Yes

No
Have you had previous psychotherapy here at Samaritan Counseling Center?(Required)

Yes

No
Are days or nights better for you(Required)

Days

Nights

Either
Do you prefer meeting(Required)

In Person

Telehealth

Either is fine
Why are you seeking counseling now?
List of Current Medication's and Dosage's

Income Information
Gross income including SSI, SS, child support, alimony, pension, Social Security, rental, and investment income
Monthly Income(Required)
Spouses Monthly Income(Required)
Other Household Income(Required)
Total Monthly Income(Required)

Health Information
Are there any health conditions your counselor should be aware of to include any allergies?
Do you have any health conditions?(Required)

Yes

No
Please Describe them
Are you currently taking any medications?(Required)

Yes

No
Please list and give the reason.

Primary Care/Provider Information
Name of Primary Physician/Provider(Required)
Physician/Provider Phone(Required)
Physician/Provider Address
Street Address Address Line 2 City State ZIP Code

Emergency Contact Info
Emergency Contact's Name(Required)
First Last
Relationship(Required)
Emergency Contact Home Phone(Required)
Emergency Contact Work Phone
Emergency Contact Cell Phone

Responsibility of Account
Person Responsible for this Account(Required)
Date(Required)
MM slash DD slash YYYY

Patient’s Name or Authorized Person Name

I authorize the release of any medical or other information necessary to process this claim.

I authorize payment of medical benefits to Samaritan Counseling Center of the Mohawk Valley for services rendered.

I accept the financial responsibility of any balance remaining on account after insurance has processed this claim

Authorized Persons Signed Name(Required)
Date(Required)
MM slash DD slash YYYY

Final Questions
Do you attend church/place of worship?
Please provide name and location
How did you learn of Samaritan Counseling Center?
please let us know how you learned of our services
Do you need an accessible location for services?(Required)

Yes

No

Personal Information

Personal Info continued

Contact Information

Contact Information

Insurance Information

Counseling History

Income Information

Health Information

Primary Care/Provider Information

Emergency Contact Info

Responsibility of Account

Patient’s Name or Authorized Person Name

Final Questions