Patient Intake Form

--Was this experience so frightening, horrible, or upsetting that, in the past month, you:

Informational Questions:

Please complete as many of these questions as you are able, your answers will be reviewed with you by your provider, and the more you complete here the more time you will have to discuss your primary reasons for seeking care.

If Yes, ensure that Sage has a copy of Guardianship/PoA paperwork and full contact information of Legal Guardian PoA, PRIOR TO YOUR FIRST APPOINTMENT.

(if yes, please specify approximately when and the reason for it, names of providers you have previously seen/currently seeing, where they work, etc. if you have this informaiton):/p>