SAGE Referral Page - SAGE Counseling, Inc.

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HOME
ABOUT US
FOR CLIENTS
SERVICES
SOCIAL RESPONSIBILITY
CONTACT US

Referrals

Referring Customers Only

Please complete the required fields and attach the Release of Information (ROI). Referrals are typically processed within 1-2 business days. If you would like to use your own referral form, please submit the referral to referrals@sagecounseling.net. Thank you.

Referral Form

"*" indicates required fields

CLIENT INFORMATION

Name*

First Last

DOB*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email

Enter Email Confirm Email

Spanish Speaking Only*

Yes

No

REFERRAL SOURCE INFORMATION

Referral Source Type*

Arizona Department of Corrections

Probation

AHCCCS Health Plans

All Others

Community Correctional Officer / APO / Referral Source*

Phone*

Email*

Enter Email Confirm Email

ROI Required

Please have your client complete and sign our Release of Information Form and upload it to this form, or fax it to our office. Or upload/fax us your own authorization form.

Attach Release of Information

Max. file size: 2 MB.

ARIZONA DEPARTMENT OF CORRECTIONS REFERRAL INFORMATION

ADC Number*

Parole End Date*

MM slash DD slash YYYY

Program Information*

ADC Transition Program (SB 1291)

ADC Drug Possession Program (DTP)

Discharge to Probation (SB 1053)

Northern Arizona Substance Abuse (NASA) ADC Program

Client's Current Charges*

Client's Location/City*

Location/City

APO / GENERAL REFERRAL INFORMATION

Case Number*

Primary Care Physician (PCP)

Optional

PCP Phone

If PCP is known

Hardcopy Referral / Additional Documentation

Drop files here or

Max. file size: 2 MB.

Additional Comments

Clinical staff will determine the necessity and level of treatment. If there are treatment recommendations or specific requirements, please explain in the comments box. Please fax court orders to (480) 649-3358, ATTN: Referrals.

REQUESTED ASSESSMENT

Requested assessment to be for:

Anger Management

Animal Cruelty Diversion

Cognitive Skills/Recidivism Reduction

Co-Occurring Program

Domestic Violence

DUI Screening

Mental Health

MVD Revocation Evaluation

Parenting Classes

Substance Abuse

Tobacco Education

Underage Drinking Program

Comments/Special Instructions

(Please describe arrest history, charge and brief reason for the recommendation)

Please provide additional information about the client

Comments

This field is for validation purposes and should be left unchanged.

SAGE Counseling does not accept cash or check payment for services.

We do accept money orders and all credit and debit cards bearing a Visa, Mastercard, American Express or Discover logo. Payment is also accepted in the form of a money order, postal money order, or cashier's check

If your referral would like to prepay for services at SAGE, please have your referral contact SAGE at (480) 649-3352 or visit our online payment page, here.

If you have questions about submitting a referral please contact SAGE Counseling at (480) 649-3352. If you have technical issues in the process of submitting a referral please, contact SAGE IT at (602) 761-4920 or by emailing us at helpdesk@sagecounseling.net.

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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