Note: To view these documents, you must have Adobe Acrobat Reader installed on your computer.
New and Return Clients:
Before your first appointment, please complete and sign the New Client Forms. For in-person counseling, please call your counselor when you arrive and they will escort you to/from the entrance. For telehealth counseling, you will need a smartphone, computer, or tablet with Internet access and audio/video capabilities; and a private, secure location.
- Client Forms Packet (required for new and return clients)
- ESPYR Statement of Understanding (for ESPYR/CG Support clients only)
- Release of Information (for clients who need to coordinate care with a family member, case manager, or healthcare provider)
- Credit Card Authorization (for current clients who want to pay by credit card) – Fillable PDF
Where to return completed forms:
- By email (scan or take photos): admin@samaritanhawaii.org
- By fax: 808-545-2852
- By mail: Samaritan Counseling Center Hawai’i, 1020 S. Beretania St., Honolulu, HI 96814
Speaker Requests:
Our counselors can lead discussion groups and workshops about a variety of mental health issues, including domestic violence awareness, grief counseling, and suicide prevention. If you need a presenter or moderator for your organization or event, please fill out the Speaker Request Form and we will respond as soon as possible.
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