Kilgore Samaritan Counseling Center

918 Ormsby Lane     Louisville, Kentucky 40220

(502) 327-4622

KSCC Account #:________________            Counselor:________________________

INSTRUCTIONS: This confidential information form is for the use of your counselor. Complete it as carefully as you can. If more than one person is coming for counseling, each should fill out a form. Please be sure to complete each question.