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.

ADC Services Referral
Please click here


Client Name : Phone number:

Client Address: City: State:

ZIP: Client DOB: Case #:


SAGE Counseling will lower the intake fee to $40 for clients who attend their first appointment. This is an incentive to motivate clients to remain compliant with terms of probation by enrolling into treatment. To be eligible for the discounted rate, clients must contact SAGE within 5 days from the date of this referral and attend their first scheduled intake appointment. Clients that miss, cancel, rescedule or contact us after the 5th day will be required to pay the full intake fee of $50.

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:
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: E-mail a copy of the referral to me

Comments:

 
 

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