SAGE Counseling Referrals

To refer clients, use our Referral Form (pdf) and fax it to (480) 649-3358,
or fill in the form below and click the Submit button to have it emailed to SAGE.

Please have your client complete and sign our Release of Information Form (pdf)

and fax it to our office. Or fax us your own authorization form.

You can also call us directly at (480) 649-3352.

Client Name : Phone number:

Client Address: City: State:

Client DOB: Case #:

RECOMMENDED TREATMENT

Substance Abuse Treatment - sessions : 30 ; 36 ; 40 ; 48 ; other
Domestic Violence
Anger Management
Lapse / Relapse
Motor Vehicle Reinstatement Evaluation
Drug Education - hours : 8 ; 16
DUI Services : Screening ; Level II Education ; Level I Treatment (hours)
Screening for: -- please choose -- Substance Abuse Domestic Violence Anger Management DUI
Screening - Clinical staff will determine the necessity and level of treatment. Discount not eligible for the screening fee.
Other:

APO/Referral Source:

Phone number: Fax number:

E-mail:

Comments: