Name *

First Name

Last Name

Which of the following issues can the service you provide be helpful for? (Please Check all that apply): *

Trauma (PTSD)

Grief

Crisis

Career

Addiction

Anxiety

Depression

Domestic Violence

Family Conflict

Relationship Issues

Spirituality

Anger Management

Behavioral Issues

Coping Skills

Domestic Abuse

Grief

Parenting

Personal Achievement / Development

Self-Esteem

Sexual Abuse

Substance Abuse

LGBTQ+ Issues

Men’s Issues

Nutrition

Sleep

Exercise

Energy Level

Physical Pain

Regular Check-ups with MD/NP

Community Life

Equal Opportunity/Discrimination

Self-Image

Spirituality

Being a minority

Are your services typically covered by MSP? *

YES

NO

Are your services covered by extended health plans? *

YES

NO

If our clients do not have coverage for your service, would you be willing to provide a discount? *

We may offer discounts on our services for clients that you refer to us.

YES

NO

Would you be interested in possibly being included in our social media with links to your website? (IE website, facebook etc.) *

Please note the following disclaimer is on our website and client intake forms: *The organizations and practitioners listed under the “Collaborators” section of our website are simple collaborations only and intended to provide our clients with, what we believe to be, high quality options. S.A.J.E. Wellness & Transition has no affiliation, contract or other interest in the above listed organizations or practitioners. When accepting services from these providers, any specific details of your treatment including payment details are an agreement between you and that provider. Unless provided with your express consent, we will never provide or share any of your information. Although we have done our best to select the highest quality of collaborators, S.A.J.E. Wellness & Transition does not guarantee their service and accepts no liability. Selecting any type of service provider is always your voluntary choice.

YES

NO

Would you be willing to possibly include us in your social media? *

YES

NO