Release of Information

FOR CLIENTS

To allow SAGE Counseling to contact or share information with another individual or outside agency, please complete a Release for each entity you would like to give permission to.

Contact SAGE

What can we help with?(Required)

Check all that apply and the appropriate departments will be contacted

Schedule an Assessment

Question(s) about my appointment

Tech support question

I need help with AHCCCS

I need to request records

The following fees will be applied to records requests:

1-20 pages = $15
21-50 pages = $30
51 + pages = $45

Delivery options:

Mail (postage will be charged)
Fax
In person pick-up

Name(Required)

First Last

Phone

Please indicate the best time to reach you between the hours of 8:30AM and 5:30PM, Monday through Friday.(Required)

Enter Email Confirm Email

Provide details(Required)

Please let us know how you were referred and the best time to contact you as well as any other relevant information.

Upload Police Reports or Court Paperwork

Drop files here or

Max. file size: 100 MB.

Upload a Release of Information(Required)

Drop files here or

Max. file size: 100 MB.

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FOR CLIENTS