Sage Center Atlanta STEP Application

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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

Email *

Age *

Date of birth *

YYYY

Address *

Phone number *

Contact options *

OK to text.

OK to email.

OK to call and/or leave a voicemail.

Required

How did you hear about STEP? *

May we contact the person who referred you to thank them? If so, please provide contact information.

Emergency contact name and relationship to you *

Emergency contact phone number *

Gender Identity *

Birth gender *

Male

Female

Highest grade of school completed *

Primary language *

Employer and job title *

Time at current job *

Relationship status *

Gross annual family income per year *

Number of people dependent on this income *

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.

Name and age of dependents not currently living with you *

Briefly describe, in your own words, your reason for seeking counseling services at this time *

Have you received counseling in the past? *

Yes

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.

Have you ever thought of or attempted suicide? *

Yes

If yes, describe when *

In the past 24 hours

In the past month

In the past year

Over a year ago

No, never thought of or attempted suicide.

Required

If yes, please briefly describe *

If no, write N/A.

Have you ever been hospitalized for psychiatric reasons? *

Yes

If yes, please briefly describe. Include where, when, and length of stay. *

If no, write N/A.

Has any member of your family ever been hospitalized for psychiatric reasons? *

Yes

If yes, please describe their relationship to you, when, and the reason for the hospitalization *

If no, write N/A.

Have you ever had a problem with alcohol or drugs? *

Yes

If yes, please briefly describe *

If no, write N/A.

Are you currently or have you ever been involved in the legal system? *

Yes

If yes, please briefly describe *

If no, write N/A.

Have you ever experienced any of the following *

physical harm and/or abuse

verbal harm and/or abuse

emotional harm and/or abuse

domestic violence, harm and/or abuse

sexual harm and/or abuse

rape

childhood harm and/or neglect

no, none of the above.

Required

If yes, please briefly describe *

If no, write N/A.

Name, phone number, and address of your primary physician *

List any major illnesses or surgeries you've had in the past 5 years *

Medications you are currently taking *

Include dosage, purpose, and prescribing physician. If none, write N/A.

Please describe your reason for requesting a reduced fee for services. Include any extenuating circumstances you would like us to consider. *

Is there anything else you'd like us to know about you?

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.

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