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Self-Referral Form
Complete this form to connect with our counseling team—your path to support starts here. Questions? Visit our website at www.sagehealingcounseling.com.
Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Email:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Provider:
Policy Number:
Group Number:
Reason for Seeking Counseling:
*
Briefly describe what brings you to counseling and what you hope to achieve
Preferred Locaiton:
McAllen
Edinburg
Telehealth
Pharr
Preferred Session Times:
*
Morning (8 AM – 11 AM)
Midday (11 AM – 2 PM)
Afternoon (2 PM – 5 PM)
Evening (5 PM – 8 PM) LIMITED
Saturday/Sunday LIMITED
Flexible/Anytime
How Did You Hear About Us?
*
Instagram
Facebook
Google Search
Saw Our Card or Flyer
Friend or Family
Healthcare Provider
Community Event
Other
Preferred Method of Contact:
*
Phone
Text
Email
Best Times to Contact You:
*
Morning (9 AM – 11 AM)
Midday (11 AM – 2 PM)
Afternoon (2 PM – 5 PM)
Submit
Should be Empty: