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SAGE Counseling, Inc

Financial Assessment Application - SAGE Counseling, Inc Skip to content

FOR CLIENTS

Financial Assessment Application

Process

(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:
  1. If currently employed: Include 3 most recent payroll stubs.
  2. 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 contains 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 104
    Mesa AZ 85210

NOTICE

The SAGE offices will be closed on Monday, January 20th, 2025 in observance of Martin Luther King Jr Day.