Family Counseling Client Forms

Please complete the following forms and bring them to your first appointment.
Client Information Form  Each person coming to therapy is to complete one of these forms.
Fee Agreement (two copies will print out – one for you and one for Samaritan) 
Fees may be set by phone beforehand with your therapist or at the first session. Each person coming to therapy is to read and sign each copy of this form.
Note: If you do not plan to use insurance, each person is to write his/her initials in the space provided on each copy.  Your therapist will sign and return a copy to you. 
Disclosure Statement (please print two copies – one for you and one for Samaritan)
Your therapist's disclosure statement may be downloaded on the Therapist Disclosure Statement Forms Page >
Please read this, print your name, sign and date it as indicated on the last page. Each person coming to therapy is to read and double-sign both copies of this form. Your therapist will sign and return a copy to you.
Notice of Privacy Practices (one copy for you)  Please read this and keep it with your records.

Samaritan Main Office
564 NE Ravenna Blvd
Seattle, WA 98115
Maps and Directions
Reach us by phone:
(206) 527-2266
(425) 732-2678
(253) 981-6575
(866) 449-9932
Fax: (206) 527-1009
E-mail:
sam at samaritanps.org