New Patients

What is your full name?

What services are you seeking?

Email

Phone Number

What are your pronouns?

he/him

she/her

they/them

Other

Date of Birth

Are you currently a resident of California?

Yes

No

Your custom variant

How did you hear about Sage Integrative Health? (if referred by a provider, please provide their name and email address if possible)

What concerns are you hoping to address?

Is there a particular practitioner at Sage who you are hoping to work with?

Do you have any previous psychiatric diagnoses?

How would you rate the symptoms you are experiencing?

I am currently:

Working with a therapist

Not working with a therapist, only looking for psychotherapy

Not working with a therapist, only looking for ketamine assisted therapy

Not working with a therapist, looking for ketamine assisted therapy and ongoing psychotherapy

Only looking for psychiatry

Do you have any medical diagnoses?

Are you currently taking any medication(s)? Please list the name and dosage for each.

Have you taken any psychiatric medications in the past? If so, which ones and when?

Have you experienced symptoms of psychosis?

Yes

No

I dont know

Have you experienced symptoms of mania?

Yes

No

I dont know

Do you have any current or past cardiac issues?

Yes

No

I dont know

Do you have a history of bladder or urinary tract issues?

Yes

No

I dont know

Have you experienced suicidal thoughts and feelings in the past or present?

Yes

No

Other:

If yes, when was the last time you had those thoughts?

Did you make a plan or acquire the means to go through with a plan?

Yes

No

Have you attempted suicide?

If yes, please list the date(s).

Have you been hospitalized? If yes, please list the reason, date, and duration of your hospital stay(s). Please specify if the hospitalization was for psychiatric, mental health, or substance abuse as well as any medical hospitalizations

If seeking Ketamine Assisted Therapy: Have you had a chance to look over our website and become familiar with the nature and cost of the treatment?

Yes

No

Do you have any questions?

Do you have any prior experience with ketamine assisted therapy?

If yes, what route of administration?

If yes, in what context?

KAT Therapy

IV Infusion Clinic

At home/Self-guided

At home (with services like Mindbloom)

If applying for ketamine-assisted therapy (KAT), would you be open to remote KAT sessions? This program allows you to engage in sessions virtually from the comfort of your own home.

Do you have any friends, family members, or acquaintances who are currently receiving treatment at Sage?

For ethical reasons we may not be able to match clients who know each other with the same mental health provider. If you answered yes above, please list your friends name and/or the name of the provider whom you contact is seeing if you know.

Is there anything that would be essential for our staff to know before contacting you?

:: SLIDING SCALE APPLICATION ::

*We reserve these spots for clients who have limited financial resources or are experiencing financial hardship.*

If you are NOT requesting sliding scale, please skip the remaining questions and simply click “Send” at the end of this form.

If you are applying for sliding scale, please complete the remaining questions. The information you provide will help us determine an appropriate rate.

Are you applying for Sliding Scale?

As part of this process, you may be asked to submit a document to verify your financial information (such as a recent tax return, pay stub, Social Security letter, or SNAP benefits letter)

YES

NO

What is your monthly gross (before tax) household income?

$0-$2999

$3000-$3999

$4000-$4999

$6000+

How many people make up your household (who are supported by the listed income)?

For Psychotherapy & KAT, will you receive insurance reimbursement for your sessions? If so, how much do they reimburse for CPT codes 90834 and 90837?

Do you have access to other means of financial support that could be used to pay for treatment (Ex. Savings, Investment, Family/Community Support, Trust Fund, Passive Income, etc.)? If yes, please describe.

What is your desired rate for each 50-minute psychotherapy session? (please note that our sliding scale is $160 - 275, depending on availability)

Is there anything else that you would like our team to know that may impact sliding scale considerations?