• Appointments Client Forms Video Therapy Donate Here Medicaid Client

    901 N Kings Highway PO Box 2967 | Myrtle Beach, SC 29577
    csccinfo@coastalsamaritan.org | (843) 448-4820 | 843 448 9875

  • Coastal Samaritan Counseling Center

    My WordPress Blog

    • Home
    • About
      • Locations
      • Accreditation
      • Employment
      • History
      • Board of Directors
    • Services
      • Counseling
      • Clergy & Congregation Care
      • Education
      • Crisis Intervention
    • Staff
      • C. Jane Osment, MAR, M.Div., MFT, LPC
      • Deb Carnosso, MSW, LISW-CP
      • Carmen Royall, MS, LPC
      • Chelsea Copeland, MA, LPC
      • Stacy Fraser, MFT, LPC
      • Michelle Estep, MA,
        LPC
      • June Tyson, Ph.D., LISW-CP
      • Philip Keilen 
      • Lisa Kroneker
      • Nicole Kroneker
    • Community Involvement
      • Partners
      • The Power of One
        • More Information on The Power of One
      • Donate
      • Awards
    • Resources
      • Newsletters
      • Media

    Client Forms

    Below are the documents you will need for your first appointment. Please bring the necessary completed forms when you come for your first appointment. You may also submit them electronically.

    Required Forms

    Client Intake Form
    Client Intake Signature Form
    Client Insurance Form
    Authorization for Credit Card Charges Form
    Video Therapy Consent Form
    Copies of Insurance Card (front & back) and Picture ID

    Optional Forms

    (print and complete if needed)

    Information Release Consent Form
    Adjusted Fee Application
    Client Satisfaction Survey

    Forms for Review

    Therapy Disclosure Information Form
    HIPAA Notice of Privacy Practices Form
    Financial Policy and Fee Agreement

    Counselor Disclosure Statements

    C. Jane Osment, M.A.R., M.Div., LPC-S, MFT
    Debra Carnosso, M.S.W., LISW-CP 
    Carmen Royall, M.S., LPC
    Chelsea Copeland, M.A., LPC
    Stacy Fraser, M.A., LPC
    Michelle Estep, M.A., LPC-A
    June Tyson, Ph.D., LISW-CP

    Insurance information can be found on the Counseling page.

    901 N Kings Highway PO Box 2967 Myrtle Beach, SC 29577

    (843) 448-4820
    843 448 9875
    csccinfo@coastalsamaritan.org

    Contact Today

    By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

    Coastal Samaritan Counseling Center, Inc
    csccinfo@coastalsamaritan.org | (843) 448-4820 | 843 448 9875

    A Website by Brighter Vision | Privacy Policy