Sage Integrative Health Initial Inquiry Form
Hello and thank you for your interest in our services at Sage Integrative Health.

The below questions are part of our intake process for booking appointments. Please fill out your answers as thoroughly as possible to help us connect you with services that will best meet your needs. This form follows HIPAA Compliance Guidelines.

If you're not comfortable filling out the online form, please give us a call and we can do the intake over the phone.

Updated 01/2025
Sign in to Google to save your progress. Learn more
What is your full name? *
What services are you seeking? *
Email Address: *
Phone Number: *
Pronouns: *
Date of Birth: *
MM
/
DD
/
YYYY
What is your home address? Please include your complete address including city and zip code. *
Are you currently a resident of California? *
What days/times are you available for appointments? *
Are you looking for in-person, virtual, or hybrid appointments?
Clear selection
What is the best way to reach you? If by phone, what are the best times? *
How did you hear about Sage Integrative Health? (if referred by a provider, please provide their name and email address if possible) *
If you selected Therapist/Provider Referral above, please share their name and email address is possible. *
If applicable, what concerns are you hoping to address? *
Are you currently in any form of treatment to address these concerns? Please describe the treatment(s) you are currently engaged in.
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Sage Integrative Health.

Does this form look suspicious? Report

Google Forms