The H.U.G. Initiative Intake Form
Healing Unresolved G.R.I.E.F. (Ghosts of the Past, Regretand Pain, Internal Turmoil, Emotional Scars, Fragmented Healing
Contact Information
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
City
State
ZipCode:
Type a question
Emergency Contact Name & Phone:
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Referral Source
How did you hear about us?*
Please Select
Court Refferal
Faith- Based Organization
Community Outreach
Self
Other
Service Needs
Please Select
Anger Management
Grief and Loss
Childhood Trauma
Family Violence
Substance Use Recovery
Parenting Support
Emotional Wellness Coaching
Other
Do you have health insurance?
YES
NO
If yes, name of provider:
Monthly or Annual Household Income:
Number of people in your household:
Employment Status:
Fulltime
Part Time
Unemployed
Student
Retired
Would you like to apply for indigent assistance?
YES
NO
Proof of income may be required (e.g.,pay stub, benefits letter, or tax return).
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Additional Comments
Please tell us anything else you'd like us to know or areas of concern:
Type your name here as your signature:
Date
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Day
Year
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