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. Forms are also available on our patient portal for online completion. Please contact Samaritan at 717-560-9969 for access to the portal.

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

New/returning client paperwork for children ages 3-10: (please download, print and complete)
Children 3-10 New Client Paperwork
If there is a legal custody agreement, one parent must complete the paperwork above and the other parent must complete:
Parent Custody Packet Children Ages 3 – 10

New/returning client paperwork for children ages 11-13: (please download, print and complete)
Children 11-13 New Client Paperwork
If there is a legal custody agreement, one parent must complete the paperwork above and the other parent must complete:
Parent Custody Packet Children Ages 11-13

New/returning client paperwork for adolescents ages 14-17: (please download, print and have only your adolescent sign the consent form)
Adolescents 14-17 New Client Paperwork
Parents of adolescents must also complete (if a legal custody agreement, both parents must complete):
Parent Agreement 14-17

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.

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.

These are our forms listed individually:

  1. Consent Form for Children 3-10
  2. Consent Form for Children 11-13
  3. Consent Form for Adolescent 14+
  4. Consent Form Adults
  5. Client Information Form
  6. Client History Form
  7. Child & Youth Additional Information
  8. Client Contacts Form
  9. Client Insurance Form
  10. Payment Authorization Form
  11. Notice of Privacy Policies
  12. Acknowledgement of Notice of Privacy Practices
  13. Authorization to Use or Disclose PHI to PCP
  14. ADULT-Self-Rated-Level-1-CC-Symptom-Measure
  15. CHILD-6-17-Parent-Guardian-Rated-Level-1-CC-Symptom-Measure
  16. CHILD-11-17-Self-Rated-Level-1-CC-Symptom-Measure
  17. Consent-for-Use-of-Email-and-Text-Communications
  18. Affirmation of No Legal Agreement
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Upcoming Programs & Events

Change Through Compassion Teen WorkshopFebruary 25 - April 15

Learn research-based mindfulness practices in this virtual workshop.

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Clergy Spouse Support – Free Program OverviewMarch 4 - March 4

Explore programs to support the well-being of those on whom clergy rely the most — their spouses

See Details
Small Business Operations and Human Resources WorkshopMarch 30 - April 20

Scale your business, review human resources, and engage with real-life scenarios.

See Details