Welcome to the Samaritan Counseling Center

Welcome to the Samaritan Counseling Center!

The counseling you are beginning is important, and we will work

with you to accomplish the changes and goals you desire.

If client is under 18, parent or guardian must also complete an application,

answer only the General, Income/Insurance and Family Data sections.

GENERAL INFORMATION

Name ______Date of Birth / / Sex M F

Home Address ______City ______Zip ______

Home Phone ______(is your home phone private/blocked?) *82 required? Y N

Work Phone ______ext. ______Cell Phone ______

Check box(es) if we may contact you: at home  on your machine(leave message)  at work

May we send you mailings at this address? Y N If not, send to:______

Emergency Contact ______Phone ______Relationship______

Would you like to receive our newsletter/mailings? Y N Social Security # ______

Current Faith______Current Participation  Active  Somewhat  Seldom  Never

If someone referred you, may we send an acknowledgment of this referral? ____ Y ____ N

Name ______Address ______

INCOME/INSURANCE INFORMATION

To make subsidies available the following information must be filled out before a fee can be assigned and counseling can begin. (Parents must complete income information for individuals under 18.)

Employer ______Occupation______

Name of School/College Attended ______Highest Level of Education Completed _____

INCOME (Gross income including child support, alimony, pension, Social Security, rental, and investment income)

Monthly $ ______Spouse’s Monthly $ ______Other household $ ______

Total Monthly Income $ ______

INSURANCE

Health Insurance Carrier______Address ______

Policy Holder’s Name ______Policy Holder’s Date of Birth ______

Insurance ID#______Group#______Primary Physician______

Primary Physician’s Address______Primary Physician’s Phone ______

FAMILY DATA

Marital Status: Single Married Divorced Separated Widowed Date of Current Marriage: ______

Name of Spouse or Significant Other ______Date of Previous Marriage: ______

Children & Ages ______Number of people in household______

(If applicable) Child’s School ______Legal Status______Guardian ______

PHYSICAL HEALTH

Age______Height______Weight______General Physical Health:  Excellent  Fair  Poor

 Major Illness?  Surgery?  Current Symptoms? Describe: ______

Allergies? Y N If yes, to what? (attach list if necessary) : ______

Currently taking medication(s)? Y NIf so, please list and describe below:

Medication______Purpose______Dose ______Prescribed by______

Allergies and/or adverse reactions to medications: ______

Date of last visit to Physician / / Reason for visit/findings______

Do you see a medical specialist? Y N If yes, please list: ______

EMOTIONAL HEALTH

 VERY HAPPY  HAPPY AVERAGE  UNHAPPY  VERY UNHAPPY

Previous psychotherapy, counseling, hospitalization or other treatment for personal and/or marital issues?

Date(s)Type of Difficulty Name of Professional/Agency

______

PLEASE DESCRIBE BRIEFLY THE MOST SIGNIFICANT ISSUES FOR WHICH YOU ARE SEEKING HELP: