If you have been directed to this registration form by your counselor, please select their name below and register your account online.
If you have not contacted Samaritan Counseling Services to receive a referral, please call our office at (941) 926-2959 so that we can match you up with the counselor that best fits your needs.
If you have not contacted Samaritan Counseling Services to receive a referral, please call our office at (941) 926-2959 so that we can match you up with the counselor that best fits your needs.
Most forms are in PDF format; you will need the current version of Adobe Reader in order to read the forms. If you don't already have Adobe on your computer it's available as a quick, free software download.
Complete the Forms
Download and save the following required forms to your computer.
Both new and returning clients must complete and return all printed and signed forms.
- The Privacy Policy (signed)
- One signed copy of your therapist's Disclosure Statement
- Privacy Policy/Disclosure Statement Signature Form
- Financial Agreement Form
Form Names
Privacy Policy
Therapist Disclosure Statement (see below)
Privacy Policy/Disclosure Statement Signature form
Financial Agreement
Client Satisfaction Survey
Informed Consent Forms
Rick Howell, Th.M., LMHC
Diane Brantley, LCSW
Dr. Elizabeth Ibanez, Ph.D
Lin A. Mertens, LCSW
Maribeth McDermott, LMHC
Donald Ross Thompson, LMHC
James Miller, LCSW
Leah Petrucci, MA, RMHCI
Linda Martin, LMHC
Richard J. Vantrease, D.Min
Print, complete and bring forms along to your first appointment.
Please keep copies of the Privacy Policy and the Disclosure Statement for your records.
