Sage Center Atlanta STEP Application
Welcome to the STEP client application!
STEP offers reduced fees, on a limited basis, based on a sliding scale according to household income.

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.

Name *
First and last name
Your answer
Email *
Your answer
Age *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Address *
Your answer
Phone number *
Your answer
Contact options *
Required
How did you hear about STEP? *
Your answer
May we contact the person who referred you to thank them? If so, please provide contact information.
Your answer
Emergency contact name and relationship to you *
Your answer
Emergency contact phone number *
Your answer
Gender Identity *
Your answer
Birth gender *
Highest grade of school completed *
Primary language *
Your answer
Employer and job title *
Your answer
Time at current job *
Your answer
Relationship status *
Gross annual family income per year *
Your answer
Number of people dependent on this income *
Your answer
Household occupants *
List name, age, and relationship to you of 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.
Your answer
Name and age of dependents not currently living with you *
Your answer
Briefly describe, in your own words, your reason for seeking counseling services at this time *
Your answer
Have you received counseling in the past? *
If yes, please list the year(s) you attended, briefly describe the reason for seeking treatment, and describe if you felt that the treatment was helpful. *
If no, write N/A.
Your answer
Have you ever thought of or attempted suicide? *
If yes, describe when *
Required
If yes, please briefly describe *
If no, write N/A.
Your answer
Have you ever been hospitalized for psychiatric reasons? *
If yes, please briefly describe. Include where, when, and length of stay. *
If no, write N/A.
Your answer
Has any member of your family ever been hospitalized for psychiatric reasons? *
If yes, please describe their relationship to you, when, and the reason for the hospitalization *
If no, write N/A.
Your answer
Have you ever had a problem with alcohol or drugs? *
If yes, please briefly describe *
If no, write N/A.
Your answer
Are you currently or have you ever been involved in the legal system? *
If yes, please briefly describe *
If no, write N/A.
Your answer
Have you ever experienced any of the following *
Required
If yes, please briefly describe *
If no, write N/A.
Your answer
Name, phone number, and address of your primary physician *
Your answer
List any major illnesses or surgeries you've had in the past 5 years *
Your answer
Medications you are currently taking *
Include dosage, purpose, and prescribing physician. If none, write N/A.
Your answer
Please describe your reason for requesting a reduced fee for services. Include any extenuating circumstances you would like us to consider. *
Your answer
Is there anything else you'd like us to know about you?
Your answer
Thank you for filling out the STEP application. A Sage Center therapist will review your information and communicate with you within two business days. If you have not heard from us, please feel free to call us at 404-419-6221 or email us at info@SageCenterAtlanta.com.
Submit
Never submit passwords through Google Forms.
This form was created inside of Sage Center. Report Abuse - Terms of Service