Inquiry Form

The following inquiry form is not a formal application for enrollment in Samaritan Center.  Its purpose is to help us learn more about your specific situation, so we can open a discussion with you to see if our program is appropriate for your child.  
 
After you fill out and submit the form, a representative from Samaritan Center will contact you within two days.  Thank you!
Use MM/DD/YYYY format.
Describe how the person inquiring knows the child: i.e., parent, grandparent, etc.