Become a Client

Gross income including SSI, SS, child support, alimony, pension, Social Security, rental, and investment income

Are there any health conditions your counselor should be aware of to include any allergies?

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