Financial Assessment Application

(For determination of sliding fee eligibility)

Please submit this application with copies of all supporting documentation as requested. The application must be filled out in its entirety and submitted.

If you are AHCCCS-eligible or believe you might be AHCCCS-eligible, STOP. Do not fill out form . Please contact the Financial Eligibility team at 602-761-4930 for further instructions

Incomplete applications or those missing documentation will not be processed for review.

Please include the following documents, if applicable:
1. If unemployed:
  - Include Three (3) most recent payroll stubs or Prior Year Federal Income Tax Return.
  - Letter of Unemployment Benefits eligibility, stating monthly $ amount; or unemployment denial letter, if applicable.
2. If currently employed: Include 3 most recent payroll stubs.
3. Documentation supporting additional sources of income to include: Social Security, Medicaid, SNAP (former food stamps) pension, annuity, veterans’ benefits, alimony, child support, military benefits, businesses, rent, interest, dividends, and any other income). Documentation should show weekly or monthly benefits.
****** If you are submitting documentation that contain social security numbers, please redact or black-out those social security numbers. *******

Please complete and return this application, along with required supporting documents, within 7 business days of receipt. Incomplete applications or applications submitted after 7 business days will not be processed and you will not be eligible for a discount.

Applications can be submitted the following ways:
- Using this form
- In Person
- Email: [email protected]
- Fax: 480-649-3358
- Mail: SAGE Counseling – Administration Office
  1830 S. Alma School Rd. Suite 104
  Mesa AZ 85210
If you are interrupted while completing this form, there is a Save and Continue Later link at the bottom of the form that can be used. Make sure you email the generated link to yourself so that you don’t have to restart the form from the beginning.
Attach files here:
Drop files here or

Max. file size: 128 MB.
Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Phone Number where you can be reached:*
Email:*
A copy of your submission will be sent to this address
Section A: Address
Physical Address (Cannot be a PO Box):*
(All applicants must provide a physical address or an address for a shelter)

Street Address Address Line 2 City State ZIP Code
I am homeless residing in a shelter:*
- Yes
- No
If you checked the box indicating that you reside in a shelter please provide the name, address and contact number for the shelter. You will also be required to complete the attached ROI (Release of Information). On the ROI, please indicate Shelter name/address. By doing this, you are giving SAGE permission to contact shelter to verify information.
Shelter Name:*
Shelter Address:*
Street Address Address Line 2 City State ZIP Code
Shelter Phone Number:*
Section B: Employment
Employment Status:
- I am unemployed due to disability. This section does not apply to me. (Please provide copy of letter of eligibility for SSI – Supplemental Security Income or SSDI – Social Security Disability Insurance)
- I have never been employed. This section does not apply to me.
- I am financially supported by someone else.
Name of Person Who is Financially Responsible for You:*
(If you are not supported by a spouse or parent, please provide a notarized letter or Power or Attorney from/for the person who is financially responsible for you.)
First Last
Relation*
Employment History:*
Please provide at least 2.
Name of Employer Address of Employer Hourly Wage Full or Part Time Dates of Employment
If you are currently unemployed and receiving unemployment benefits, please attach a copy of letter of eligibility. If you are currently unemployed and not receiving unemployment benefits, please provide copy of AZ Dept of Economic Security (DES) response letter.
Drop files here or

Max. file size: 128 MB.
Section C: Household Information
I reside in a homeless shelter. This section does not apply to me.*
- Yes
- No
Including yourself please list any person(s) residing at the address you provided in section A. If you have included more than yourself, please provide page 1 of prior year Federal income tax return for Head of Household to verify household size.
Name Relationship to the Applicant Date of Birth
Head of the Household:
Head of Household Definition: An individual in one family setting who provides actual support and maintenance to one or more individuals who are related to him or her through adoption, blood, or marriage.
First Last
If household size is greater than 1(one), please provide page 1 of prior year Federal Income Tax Return for Head of Household if it is not Yourself
Drop files here or

Max. file size: 128 MB.
Section D: Monthly Household Income
List all MONTHLY GROSS INCOME amounts from all sources for Yourself, your Spouse, and Head of Household.
Wages, Salaries, Tips, etc.
Self*
Spouse*
Head of Household*
Total
Social Security, Pension, Veterans’ Benefits
Self*
Spouse*
Head of Household*
Total
Alimony, Child Support
Self*
Spouse*
Head of Household*
Total
Supplemental Nutritional Assistance Program (SNAP, formally Food Stamps)
Self*
Spouse*
Head of Household*
Total
Income from Business, Rent, Interest, Dividends
Self*
Spouse*
Head of Household*
Total
Other Income
Self*
Spouse*
Head of Household*
Total
Unemployment
Self*
Spouse*
Head of Household*
Total
Total – Self
Total – Spouse
Total – Head of Household
Grand Total*
Section E: Supplemental Nutrtion Assistance (SNAP Formally Food Stamps)
SNAP/Food Stamps*
- I receive state-funded nutritional assistance/food stamps.
- I do not currently receive state-funded nutritional assistance/food stamps.
Amount recieved from SNAP/food stamps
SNAP/Food Stamps received for a family of:
Letter of Eligibility
Max. file size: 128 MB.
Section F: Verification Documents
Please provide the following verification documents where applicable and check the box indicating which documents you are providing.
Please attach all of the following for yourself, your spouse, and your head of household. Missing documentation will delay the approval process.
- If Unemployed: Three (3) most recent payroll stubs or Prior Year Federal Income Tax Return
- Letter of Unemployment Benefits eligibility, starting monthly $ amount -or- that benefits were denied
- If currently Employed: (3) most recent payroll stubs are required
- Letter of Nutritional Assistance eligibility, stating monthly amount
- Other Applicable Documents
Documentation for Self, Spouse, and Head of Household*
Drop files here or

Max. file size: 128 MB.
I certify that the household size and financial information presented in this application are true and accurate. I understand that SAGE Counseling will make efforts to verify the accuracy of this information. I further understand that SAGE Counseling is using this information exclusively for the purpose of determining whether I qualify for the Discounted Fee Program
Signature*
Name*
First Last
Date*
MM slash DD slash YYYY
Authorization for Release of Information
Only required if living in residential shelter
Name*
First Last
DOB*
MM slash DD slash YYYY
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Cell
Case #*
Purpose of disclosure*
Please, leave the “other” selection checked in order for SAGE Counseling to verify your residence.
- Coordination with Probation/Parole/Court/Legal System
- Coordination with DES
- Coordination of Care
- Other: To verify residence
Check boxes below to release, for the continuity of care and to maintain my medical record, protected health information related to any of the following or check ALL below, except progress notes, if ROI is for your referral source.*
Please, leave the “Other” option checked so that SAGE Counseling may verify Shelter Residence.
- Assessments/Evaluations/Diagnoses
- Psychiatric/Mental Health Information
- Child Abuse/Neglect
- Oral Communication
- Progress Update Reports
- Progress Notes
- Discharge Summary
- Medical Information
- Treatment/Service Plans
- Alcohol and/or Drug Use
- Probation/Parole/Court/Legal Requirements
- Other: Shelter Residence verification, address, location, date of entry and expected length of residency.
I understand that my protected health information may be used and disclosed to carry out treatment, for payment of services, or for healthcare operations to improve the quality of care by SAGE. I acknowledge receipt of the SAGE Notice of Privacy Practices and I understand that I have the right to review the Notice before signing this consent. I understand that any changes in the Notice will be posted at all SAGE sites and are available to me upon request. I understand that this authorization is in effect for one calendar year from the date on this form. The confidentiality of alcohol and/or drug abuse client records maintained by SAGE is protected by federal law and regulations. Except under special circumstances, SAGE may not orally disclose to a person outside the program that a client attends the program. SAGE also may not disclose any information identifying the client’s history of alcohol and/or drug abuse unless: by written authorization by the client; by written court order; or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation process (Federal Law references 42 U.S.C. 290 dd-3 – Federal Regulation reference CFR, Part 2). I understand that I have the right to request in writing that SAGE restrict how my protected health information is used to carry out treatment, payment, or health care operations. I understand that SAGE is not required to comply with my request. I understand that I have the right to revoke in writing this authorization to release my protected health information.
Client Name*
First Last
Client Signature*
Client Signature Date*
MM slash DD slash YYYY
Legal Representative Name
First Last
Legal Representative Signature
Legal Representative Signature's Date
MM slash DD slash YYYY
Witness Name*
First Last
Witness Signature*
Witness Signature Date*
MM slash DD slash YYYY

Save and Continue Later

Financial Assessment Application

If you are submitting documentation that contain social security numbers, please redact or black-out those social security numbers. *

If you are interrupted while completing this form, there is a Save and Continue Later link at the bottom of the form that can be used. Make sure you email the generated link to yourself so that you don’t have to restart the form from the beginning.

Section A: Address

Section B: Employment

Section C: Household Information

Section D: Monthly Household Income

Wages, Salaries, Tips, etc.

Social Security, Pension, Veterans’ Benefits

Alimony, Child Support

Supplemental Nutritional Assistance Program (SNAP, formally Food Stamps)

Income from Business, Rent, Interest, Dividends

Other Income

Unemployment

Section E: Supplemental Nutrtion Assistance (SNAP Formally Food Stamps)

Section F: Verification Documents

Please attach all of the following for yourself, your spouse, and your head of household. Missing documentation will delay the approval process.

Authorization for Release of Information

Name of Employer	Address of Employer	Hourly Wage	Full or Part Time	Dates of Employment

Name	Relationship to the Applicant	Date of Birth

Financial Assessment Application

****** If you are submitting documentation that contain social security numbers, please redact or black-out those social security numbers. *******

If you are interrupted while completing this form, there is a Save and Continue Later link at the bottom of the form that can be used. Make sure you email the generated link to yourself so that you don’t have to restart the form from the beginning.

Section A: Address

Section B: Employment

Section C: Household Information

Section D: Monthly Household Income

Wages, Salaries, Tips, etc.

Social Security, Pension, Veterans’ Benefits

Alimony, Child Support

Supplemental Nutritional Assistance Program (SNAP, formally Food Stamps)

Income from Business, Rent, Interest, Dividends

Other Income

Unemployment

Section E: Supplemental Nutrtion Assistance (SNAP Formally Food Stamps)

Section F: Verification Documents

Please attach all of the following for yourself, your spouse, and your head of household. Missing documentation will delay the approval process.

Authorization for Release of Information

If you are submitting documentation that contain social security numbers, please redact or black-out those social security numbers. *