Sage Therapy & Education Partnership STEP Program Application

The information on this form and all other information gathered by this office is confidential.

Do we have your permission to contact you via email and/or text message?

Note: Confidentiality cannot be guaranteed in emails and text messages; however, we recognize that those methods may be preferred by some. If you would like to give your permission to utilize text messaging and/or email, enter your contact information below. If you do not wish to use email and/or text messaging, please leave this section blank.

Whom may we contact, with your permission, in case of emergency?

( The amount of money that comes into your household before taxes.)

List everyone currently living in your household (include housemates, spouse, partner, and all children; include any different last names and if minor is from two households):

Please include person's name, age & relationship to you.
Please include person's name, age & relationship to you.
Please include person's name, age & relationship to you.
Please include person's name, age 7 relationship to you.
Please include person's name, age & relationship to you.

If yes, please list the year(s) you attended and briefly describe the reason for seeking treatment at that time and if you felt treatment was helpful for you:

List any medications you are presently taking:

The mission of Sage Center is to promote comprehensive wellness within our community by providing quality support services through counseling, consultation, education, and mentorship to individuals, professionals, and organizations. Sage Center is committed to serving with integrity, compassion, and respect in a balanced and collaborative environment.

Sage Therapy and Education Partnership (STEP) is a program developed and overseen by Sage Center in which master's level counseling interns and post-master's counseling residents provide counseling and psychotherapy services under intensive supervision by an experienced Licensed Professional Counselor/Certified Professional Counselor Supervisor. At Sage Center, we believe that mental health is essential to the overall well-being of individuals, families, and communities. The STEP program was developed to help provide counseling and psychotherapy to members of the community who may need financial assistance in order to access such services, and to promote quality training opportunies for counseling interns and beginning level counselors. The STEP program offers reduced fees, on a limited basis, based on a sliding scale according to household income. Your financial information will be reviewed by a Sage/STEP representative to determine your fee for services. You must provide offical documentation of your income by bringing one of the following to your first session: W-2, pay stubs from previous 2 months, or copy of IRS form 1040 for most recent year's tax returns.

The amount of money that comes into your household before taxes.

Please describe your reason for requesting a reduced fee for services - include any extenuating circumstances you would like for us to consider: