2026 HUGS Consultation Questionnaire

Your Consultation Provider is a Mandated Reporter

In Georgia, mandated reporters include various professionals who work with children and have a legal obligation to report suspected cases of child abuse or neglect. These reporters must report their suspicions to the Department of Family and Children Services (DFCS) or law enforcement, within 24 hours, according to Georgia Child Protective Services (DFCS). Failure to do so can result in criminal penalties.
Name

FirstLast Name
Preferred Name
Birthdate

MonthDayYear
Date
Age
Gender
Pronouns
Phone
Format: (000) 000-0000.
Email
example@example.com
Preferred contact method
Is Voicemail OK?
Is Texting OK?
Have you Ever received Counseling Services?

YesNo
If yes, what Kind of Services?

In-patientOut-patientResidentialGroup
When were you recieving services? (month/year- month/year)
Why were you receiving services?
Is there anything you liked about those services?
Is there anything you disliked about those services?
Have you ever had any previous diagnoses?

YesNo
If yes, what Diagnoses?
Are you currently recieving services?

YesNo
If Yes, what Kind?

In-patientOut-patientResidentialGroup
Where do you go? Who do you see for services?
Have you ever experienced in the past?

Suicidal IdeationHomicidal IdeationAuditory HallucinationsVisual HallucinationsNone of the above
Are you currently experiencing?

Suicidal IdeationHomicidal IdeationAuditory HallucinationsVisual HallucinationsNone of the above
If yes, when? Explain
Are you currently prescribed any psychiatric medication?
If yes,what are you prescribed?
Who prescribed it?
Date prescribed?

MonthDayYear
Date
Are you compliant with how those medications are prescribed?

YesNo
If no, why not?
Have you been prescribed psychiatric medication in the past?

YesNo
If yes, explain what you were prescribed and why:
Are you currently participating in any high risk behaviors?
Are you currently using any un-prescribed substances?

YesNo
How often do you use alcohol?
How often do you use Marijuana?
How often do you use THC?
How often do you use CBD?
How often do you use Amphetamines?
How often do you use Barbiturates?
How often do you use Benzodiazepine?
How often do you use Cocaine?
How often do you use Opioids?
How often do you use "other" substance? (please list what substances)
How did you hear about HUGS
What services are you interested in? (choose all that apply)

Individual TherapyCouples TherapyFamily TherapyIntensive Out-patient ServicesGroup Therapy
What do you expect to gain from counseling
What is your availability? (more is better)
Are you willing to participate in recording for educational purposes ONLY?

YesNo
While we cannot guarantee a certain gender, race, ethnicity, sexual orientation, etc. of your counselor, we try your counselor we try our best to accommodate when possible. Please list any preferences here:
If you have a specific trauma response to a certain gender, race, ethnicity, sexual orientation, etc. PLEASE let us know so we can provide a safe and welcoming environment for all.
About HUGS:
- We are 100% Volunteer Counselors

- You must be motivated, consistent, and compliant

- You are expected to maintain frequency of care set by your counselor, with the possibility of increasing if clinical need is determined.

-Reschedules must be made 24hrs in advance to avoid charges, excessive reschedules are considered non-compliant

- More availability helps to schedule sessions effectively

- Sessions are pre-paid; Cards are charged on Monday. Cash or Checks must be collected at previous session

CLIENTS MUST BE COMPLIANT WITH SCHEDULING AND BILLING TO STAY AN ACTIVE CLIENT
Should be Empty:

Your Consultation Provider is a Mandated Reporter

About HUGS: