2023 Consultation Request Form

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.
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
Are you currently receiving services?*

YESNO
If yes, explain:
Type of service, where and how often or N/A
Have you ever experienced any of the following in the past:*

Suicidal ThoughtsHomicidal ThoughtsAuditory HallucinationsVisual HallucinationsNone of the above
Are you currently experiencing any of the following:*

Suicidal ThoughtsHomicidal ThoughtsAuditory HallucinationsVisual HallucinationsNone of the above
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*
How did you hear about HUGS?
What services are you interested in? (Choose all that apply)*

IndividualCouplesFamilyIntensive Outpatient ServicesGroup
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*

MonthDayYear
Date
Should be Empty: