2023 Consultation Request Form

About HUGS' Services

We operate with 100% professional volunteers who all volunteer their time to serve our clients. Our professional volunteers all range from Master’s Level Interns to Post-graduate and Associate Licensed clinicians, as well as fully licensed clinicians. Interns, Post-Graduate and Associate Licensed clinicians are all regularly supervised by fully licensed clinicians.

HUGS provides outpatient services to a motivated and high functioning population. In an outpatient setting, we are not available in case of emergency and/or crisis. We expect you to be able to go 24 hours without receiving a text or phone call response, as well as being able to go a week between sessions. If these things are not possible, you might need a higher level of care. Our clinical staff is trained to recognize and refer to higher levels of care as indicated or requested to ensure you can effectively meet your treatment goals.

Therapeutic rapport is essential; and you may request a change in assigned counselor at any time. However, due to clinician scheduling and availability, you may need to be placed back on the waiting list temporarily.

A free 15 minutes consultation is the first step in receiving services at HUGS. This allows us to better understand your needs, and make recommendations for services that best support you in your mental health jouney.

Please complete this form to get started. If you are in crisis please call 911, 988 or go to the nearest emergency room. Additional resources can be found here: https://www.headsupsavannah.org/resources

Name*

First Name Last Name

Pronouns

Age*

Age of person seeking services

Phone*

Email Address: *

Preferred contact method ?*

(call, text, email)

Can we leave a voicemail?*

Can we text you? *

Have you ever received counseling services?*

YESNO

If yes, when? *

Enter date(s) or N/A

If yes, what brought you to those services?*

Enter a short explanation or N/A

Did you receive any diagnoses during those services?

If yes, please indicate what diagnosis.

Are you currently receiving services?*

YESNO

If you are receiving services at this time, what kind?

In-PatientOut-PatientResidentialGroup

If yes, explain:

Type of service, where and how often or N/A

Have you ever experienced any of the following in the past:*

Are you currently experiencing any of the following:*

If yes, please explain*

Include dates and a short description of incidents or N/A.

Are you currently prescribed any psychiatric medication?*

Type Yes or No

If yes, what medication?*

put N/A if none

Who prescribed the medication?*

Prescribing Doctor's name put N/A if none

Are you compliant with how those medications are prescribed?*

YesNo

If not, please explain*

Are you currently participating in any high risk behaviors?

How did you hear about HUGS?

What services are you interested in? (Choose all that apply)*

What do you expect to gain from counseling? *

A short explanation of your goals.

What is your availability? *

Include days and times that work best for you, more is better.

Additional notes

Date