SAGE Counseling, Inc.
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  • HOME
  • ABOUT US
    • - About Us
    • - Our Clinical Managers
    • - Leadership Team
    • - Client Success Stories
    • - Employment
    • - Office Locations
    • - SAGE Holiday Schedule
    • - News Room
  • FOR CLIENTS
    • - Schedule an Appointment
    • - Client Portal
    • - Make a Payment
    • - Financial Assessment Application
    • - Moodle Pilot Program
  • SERVICES
    • - Services
    • - Departments
    • - Referral Forms
    • - Referring Customer Log-in
    • - Make a Payment
    • - Records
  • SOCIAL RESPONSIBILITY
  • CONTACT US

  • (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 Admissions Specialists team at 480-649-3352 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: DFA@SAGEcounseling.net
    • Fax: 480-649-3358
    • Mail: SAGE Counseling - Administration Office
              1830 S. Alma School Rd. Suite 101
              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.

  • Drop files here or
    Max. file size: 2 MB.
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    • A copy of your submission will be sent to this address
    • Section A: Address

    • (All applicants must provide a physical address or an address for a shelter)
    • 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.
    • Section B: Employment

    • (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.)
    • Please provide at least 2.
      Name of EmployerAddress of EmployerHourly WageFull or Part TimeDates of Employment 
    • Drop files here or
      Max. file size: 2 MB.
      • Section C: Household Information

      • NameRelationship to the ApplicantDate of Birth 
      • 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.
      • Drop files here or
        Max. file size: 2 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.

        • 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)

        • Max. file size: 2 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
        • Drop files here or
          Max. file size: 2 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
          • Reset signature Signature locked. Reset to sign again
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          • Authorization for Release of Information

            Only required if living in residential shelter
          • MM slash DD slash YYYY
          • MM slash DD slash YYYY
          • Please, leave the "other" selection checked in order for SAGE Counseling to verify your residence.
          • Please, leave the "Other" option checked so that SAGE Counseling may verify Shelter Residence.
          • 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.
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          Save and Continue Later

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          Our Mission

          The mission of SAGE Counseling is to demonstrate responsible concern in order to advocate for clients, customers, and staff.   We do this by promoting responsible, ethical choices that will lead to long term success.

          Contact Us

          • Email
            info@sagecounseling.net
          • Phone
            (480) 649-3352
          • Address
            1830 S. Alma School Rd. Suite 101, Mesa, AZ 85210

          Office Hours

          Monday - Friday
          8:30 AM - 5:30 PM

          Saturday
          9:00 AM - 12:00 PM

          SAGE Counseling, Inc - 2017