A thorough assessment is important because it can provide your counselor/coach with helpful information about your background. In an effort to ensure that counselor/coach can spend time in-session focusing on what is most important to you instead of collecting this information, we ask that you complete this packet and submit it before your first appointment

    May we...

    Leave messages at the above phone numbers?

    Send appointment reminders via text message to the above cell number?

    Contact you via email if we cannot reach you by phone?

    Email you payment receipts for services?


    FINANCIAL POLICY Full payment is due at time of service (unless prior arrangements have been made). Please feel free to ask if you have any questions about our financial policy. Understanding our financial policy is important to our relationship. Aubrey & Hugh does not take or accept any Insurance policy for payment. You are responsible for the timely payment of your Account. Uncollected balances may be turned over for collection or reported to the state’s attorney’s office. Payments can be made via PayPal using link: paypal.me/DrWAR or by using the email aubreyandhugh@gmail.com

    CANCELLATION POLICY Please help us to serve you and others better by keeping your scheduled appointments. If you need to cancel or reschedule, please give us as much notice as possible so we can offer that time to someone else. Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal consultation session. This will be billed to you. We may require prepayment in order to schedule a subsequent appointment.

    CONFIDENTIALITY Federal and State laws protect your confidentiality (See 42 U.S.C. 290dd-3 and 290ee-3 for Federal laws and 42 CFR Part 2, section 33.13 of the Mental Hygiene Law-NY State). Your counselor/coach will not share information with any person outside of Aubrey & Hugh Consulting LLC, without your written permission.

    Exceptions to Confidentiality: Federal regulations do not protect from disclosure of information related to a client’s involvement in a crime against property or personnel. We are required under State law to report suspected abuse of a child, elderly person, or individual with a disability. We may share limited information in the event of a medical emergency or in the event of a specialized court order signed by a judge. Your counselor/coach has the option of breeching confidentiality if you report a specific plan or intent to cause serious bodily harm to an identifiable person.

    CONSENT TO LIFE STRATEGIZING SERVICES I am voluntarily seeking counseling/coaching services from Aubrey & Hugh Consulting LLC,. I understand that I have rights and responsibilities regarding my participation in my life management work, including the right to discontinue. I am strongly encouraged to discuss my coaching plan and status in sessions with my counselor/coach. Counselors will also discuss alternatives, procedures, qualifications, and drawbacks to any particular counseling approach. With my signature below, I acknowledge that I have read, understand, and agree to all of the above. I also acknowledge that I have been informed of HIPPA/Privacy Practices implemented here at Aubrey & Hugh Consulting.

    Individual/group counseling/coaching sessions are intended to be 45-55 minutes in length, at price rate that begins at $55.00 per session.

    Please note: We do not provide emergency services. In true crisis call 911.


    Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.”

    Psychosocial History

    Treatment History

    Have you ever participated in counseling, psychotherapy, psychiatric/mental health treatment, or substance abuse treatment? Other services? If so, please complete the following information to the best of your ability:
    Date(s) | Provider | Purpose/Focus of Treatment | Outcome

    Trauma History

    Did you experience any physical, sexual, or emotional/psychological abuse or neglect during childhood or as an adult? If so, please describe:

    Have you had any experiences you’d consider to be traumatic (e.g., threat of serious harm/injury, natural disaster, victim of a crime, traumatic losses/deaths, etc.)? If so, please describe:

    Has anyone in your family ever been diagnosed or treated for a mental health disorder or for an alcohol- or drug-related problem? Has anyone had these problems but not been treated? If either apply, please indicate below: Family Member | Problem/Disorder | Describe Treatment (if any)

    Medical Conditions & History

    Do you have any current or recent medical/physical concerns?

    Do you have a primary care physician?
    Name of Physician/Practice:

    Please describe any history of surgeries, significant medical procedures, or ER visits, or major illnesses (including dates if possible):

    Medications (including dosages, prescribing physician, and purpose of medication):


    Substance Use

    Please enter the following information for any substances including alcohol, tobacco, and drugs that you currently use or have used in the past:

    Past Use? yesno
    Current Use? yesno

    Family History

    Were you adopted? yesno

    Who lived with you growing up?

    Did you have brothers or sisters? yesno

    If so, list their names and ages:

    Did/do you have stepparents?yesno
    How would you describe your family growing up?
    What was your parents’ relationship with each other like?
    What was your relationship with your mother like growing up?
    What is your relationship with her like now (if living)?
    What was your relationship with your father like growing up?
    What is your relationship with him like now (if living)?

    Did you experience any physical, emotional, or sexual abuse or neglect as a child or as an adult?

    What is your relationship status (check all that apply)?

    If you chose "other", describe:

    Do you have children? yesno

    Names and ages:

    Social, Spiritual, & Developmental History

    Where were you born?
    Where did you live growing up?
    Were there any complications with your birth?
    Were there any developmental delays growing up
    What were your friendships like growing up?
    Describe your friendships now:
    Who do you turn to for support?
    How many serious relationships have you been in your life?
    Describe your history of romantic relationships:
    Are you in a relationship now?yesno
    If so, for how long?
    Describe your relationship with your significant other
    Describe your sexual orientation: If other describe:
    Describe your religious or spiritual beliefs:
    Describe any social groups or institutions you are involved in (e.g., clubs, associations, congregations):
    What do you do in your spare time?

    Educational and Vocational History

    What was school like for you growing up?
    What is the highest level of education/highest grade you completed?
    If you went to college or grade school, what degrees or certifications did you earn?
    Describe your employment history:
    Are you working now?yesno
    What is your occupation?
    Are you satisfied with your Annual income?
    Describe any vocational/occupational goals you may have for the future

    Legal History

    Have you ever been arrested? If so, when and what charge(s)?
    Describe any current legal concerns:

    Other Information

    What are your strengths?
    Anything else you want us to know?

    If yes describe: