Services & Resource Application

Thank you for reaching out for services at our center. One of our Intake Specialists will reach out within 48 hours.

Full Name

Date of Birth

Phone Number

Email address

Street Address

Street Address Line 2

City

State

Postal/Zip Code

County

Have you or a family member ever served in the military?

Active Duty

Veteran

Spouse of a service member/veteran

Surviving spouse

Minor dependent of a service member/veteran

N/A

I am interested in joining the Hope for Heroes program. This program requires documentation to prove military status such as DD214 or MILITARY ID, etc. to qualify for free or reduced fee services

Tell me more

I am interested in:

Individual Therapy

Couples Therapy

Family Support

Group Therapy

Acupuncture

Nutrition/Wellness Services

Peer Support

Military Connected Resources

Counselor Preference

No preference

Female

Male

Brief description of your needs and/or goals. Please do not share personal details or provide in-depth information

Scheduling preferences (mornings, afternoons, certain days) or no preference? Note: Flexibility assists in quicker scheduling

I am looking for sessions that are:

Virtual

In-Person

Open to either virtual or in-person

I am interested in scheduling with a Graduate-Level Counseling Intern for $10 per session for Spring/Summer sessions. Learn more about each available intern:

Ashlynn PriestGraduate Student Intern (samaritan-center.org)

Evan PartchGraduate Student Intern (samaritan-center.org)

Jenn SchmidtGraduate Student Intern (samaritan-center.org)

Note: These sessions are free for veterans, service members, minor children and spouses of military families with proper proof of military under our Hope for Heroes program.

Interested in scheduling with Graduate-Level Intern

How will you pay for services?

Insurance

Private Pay

Apply for Financial Assistance

For military families, non-insured clients and those with limited or no income, you may qualify for free or low-cost services. Please complete the fields below to help us identify grant program funding available to assist you. Supporting documentation will be required to qualify. Our full fee: $175 initial counseling session/$150 for ongoing counseling sessions; $45 for initial acupuncture sessions/$40 for ongoing acupuncture. If you are unable to afford our full rates, you may apply for financial assistance for reduced rates.

Annual gross income (for entire household):

How many people are supported by this income?

Please complete all insurance information if you wish to use insurance. Relationship to policy holder:

Self

Spouse

Dependent

Policy Holder’s Name & Date of Birth:

Primary Insurance Company

Member ID

Group #

Phone#: 800 # located on back of Ins card “For Providers”

Secondary Insurance Company

Member ID

Group #

I am also interested in being connected to services/resources for:

Education

Employment

Food Assistance

Financial Stability

Housing

Military Peer Mentorship

Obtaining Health Insurance

How did you hear about our services?

Doctor

Dripping Springs ISD

Family

Friend

Insurance Company

Online

School

Social Agency

Other

How did you hear about our services?

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