Client Forms

New client paperwork, as well as a copy of a government issued photo ID (such as your driver’s license) and a copy of your insurance card(s), may be returned to the Center via:

  • Fax at 717-560-9553
  • Regular mail to Samaritan Counseling Center, 1803 Oregon Pike, Lancaster, PA 17601
  • Dropped off at our office between 8 am and 4 pm Monday through Thursday or 8 am and 2 pm on Fridays.

Paperwork for New Clients

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 ensure these items are at the Center one week prior to your first session.

New client paperwork for adults: (please download, print and complete)
Adult New Client Paperwork

New client paperwork for children and adolescents: (please download, print and complete)
Child and Adolescent New Client Paperwork

For Adult clients returning to the Center and last visit was less than one year ago (if last visit was greater than one year ago, please complete new client paperwork above): (please download, print and complete)
Adult Returning Client Paperwork

For Child and Adolescent clients returning to the Center and last visit was less than one year ago (if last visit was greater than one year ago, please complete new client paperwork above): (please download, print and complete)
Child and Adolescent Returning Client Paperwork

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.

Consent Forms for Videotherapy:
Consent to VideoTherapy Services
Consent for Use of Email and Text Communications

Consent Form for In-Person Services:
Consent for In-Person Services

These forms should be signed and sent via one of these methods:

  • Fax at 717-560-9553
  • Regular mail to Samaritan Counseling Center, 1803 Oregon Pike, Lancaster, PA 17601
  • Dropped off at our office between 8 am and 4 pm Monday through Thursday or 8 am and 2 pm on Fridays.

You may verbally consent to these forms by reviewing the form(s) and then contacting Samaritan at 717-560-9969. You will need to speak with two staff members in order to confirm your verbal consent.

These are our forms listed individually:

  1. Adult Self Report Form
  2. Counseling Policy
  3. Fee Policy
  4. Notice of Privacy Practices
  5. Acknowledgement of Receipt of Notice of Privacy Practices
  6. Authorization to Use or Disclose Health Information From/To Primary Care Physician
  7. Symptom Measurement for Adults
  8. Symptom Measurement (Parent/Guardian Rated) for Children 6-17
  9. Symptom Measurement (Self-Rated) for Children 11-17
  10. Consent for Use of Email and Text Communications
  11. Consent for In-Person Services OR
  12. Consent to VideoTherapy Services
  13. Client Update Form
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Upcoming Programs & Events

Change Through Compassion WorkshopJune 17 - August 12

This workshop provides participants with the opportunity to gain experience in mindfulness and self-compassion by deepening their own wisdom through an emphasis on practice.

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2021 Ethics In Business AwardsJuly 22

Join us for an evening honoring local businesses and organizations committed to ethics! The hybrid in-person and livestream event will feature a keynote address from Jan Bergen, retired CEO and president of Penn Medicine Lancaster General Health.

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2021 Silent Samaritan LuncheonNovember 11

Ripples of Hope & Healing: The Many Colors of Creativity This year’s Silent Samaritan luncheon event will feature poetry, music, art and a testimonial from Diane…

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