Intake Form

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Intake Form

STEPS TO TAKE:

If you are feeling suicidal and/ or in danger, call 988 in the USA or Canada or your local emergency number, and do not delay.
HUG is not a crisis line. You should contact a crisis line in your country if you need to talk with someone now.
If you are not in crisis, you should connect with the support agencies in your community, and/or make an appointment to meet with your professional medical advisor (GP).
You can contact us by email here. We will get back to you with a non-emergency response as soon as is practicable.

If you have tried all 3 steps, we’re here to listen:

The more you share, the better we can understand your situation and respond with relevant, helpful support. Please explain as if to someone who doesn’t know you, so we can provide the right guidance as quickly as possible. All information is kept confidential, except where safety concerns require action.

We’re listening and taking you seriously!

* denotes a required field

Immediate Safety

Are you in immediate danger? Are you in immediate danger? Yes No

If yes, please contact the emergency number in your country immediately

Are you thinking about harming yourself or someone else? Are you thinking about harming yourself or someone else? Yes No

If yes, please contact the emergency number in your country immediately

Do you have access to means of harm right now? Do you have access to means of harm right now? Yes No

If yes, please describe briefly:

Age Range

About You

Gender Identity

Location (City/Town, Province/State)

Primary Language

Specific communities you identify with (optional)

Reason for Contact

Main issue(s) you are facing today Main issue(s) you are facing today Suicidal thoughts Mental health crisis Abuse or violence Substance use Homelessness or housing crisis Relationship or family conflict Financial crisis Others

Please describe

Current Supports

Do you have a mental health professional or counsellor? Do you have a mental health professional or counsellor? Yes No

Why have you not connected with a mental health professional or counsellor?

Do you have friends/family you can talk to? Do you have friends/family you can talk to? Yes No

Are you connected to any support services? Are you connected to any support services? Yes No

If no, please describe

Is there anything else you feel you would like to tell us?

Consent & Confidentiality

Our services are confidential, except if we believe you are at risk of harming yourself, someone else, or if required by law. By submitting this form, you agree to YLC responding/communicating with you via email. Our services are confidential, except if we believe you are at risk of harming yourself, someone else, or if required by law. By submitting this form, you agree to YLC responding/communicating with you via email. Please confirm you have read and agree to our terms of terms of use

Would you like to receive a copy of this form by email? Would you like to receive a copy of this form by email? Yes No

About Us

HUG is an award-winning movement of compassion, standing with people through life’s hardest moments, rekindling hope, and celebrating the unshakable value of every life.

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Humanity Unlimited Global, Inc. is a federally registered not for profit charitable organization; CRA#135891257RR0001