The Samaritan Counseling Center’s mission begins and ends with people and our community.

Forms

We are aware that you may be waiting many weeks to see a therapist. We are excited to begin offering the “Enhancing Emotional Health Series” to provide support and information in the interim. 
Cost: $30 per class. Classes can be taken alone (they do not necessarily build on each other) or if you’d like to take all of them, a discounted price for all is offered. If a date does not work for you and you’d like to take a particular class later, they will all be offered on a continual basis.  For more information, please click here

Client Forms

Pursuant to the Federal Trade Commission’s Red Flags Rule, we must request a copy of your insurance card (if applicable) and a copy of a government issued photo ID (such as your driver’s license). Please bring these items to your first session.

New client paperwork for adults: (please download, print and complete)
Client Self Report Form (pdf)
Counseling & Fee Policy (pdf)
Consent Form (pdf)
Privacy Notice (pdf)
Information Authorization for Primary Care Physician (pdf)
Symptom Measurement for Adults

New client paperwork for children and adolescents: (please download, print and complete)
Child & Adolescent Report Form (pdf)
Counseling & Fee Policy (pdf)
Consent Form (pdf)
Privacy Notice (pdf)
Information Authorization for Primary Care Physician (pdf)
Symptom Measurement (Parent/Guardian Rated) for Children 6-17
Symptom Measurement (Self-Rated) for Children 11-17

For clients returning to the Center: (please download, print and complete)
Client Update Form (pdf)
Counseling & Fee Policy (pdf)
Consent Form (pdf)
Privacy Notice (pdf)
Information Authorization for Primary Care Physician (pdf)
Symptom Measurement for Adults
or
Symptom Measurement (Parent/Guardian Rated) for Children 6-17
Symptom Measurement (Self-Rated) for Children 11-17

For clients participating in the Jump Start for Couples Consultation: (please download, print and complete)
Jump Start for Couples Questionnaire
Symptom Checklist for Jump Start for Couples Symptom Checklist

For clients requiring an Authorization to Use or Disclosure of Health Information:

Authorization to Use or Disclose Health Information

If you would like these forms mailed to you, please call us at 717-560-9969.

KEY INITIATIVES

Teen Depression & Suicide

Implementing a proven teen-screening program in Lancaster County schools that identifies students struggling with depression, suicidal thoughts, anxiety and substance use.

Learn more »

Child Sexual Abuse

Expanding the Center’s nationally-recognized Safe Church Program that provides education and training to future pastors, volunteers and staff working with children.

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Ethics in Business

We shine the spotlight on local businesses and organizations that “do well by doing good,” while our annual program provides resources for people looking to establish ethics best practices.

Learn more »