HUGS Participant Forms

All Program Participants are asked to return all of the applicable forms (below) to “Attention: HUGS” via fax at 239-330-7163.         

CONSENT FORMS – REQUIRED

• From 3 months to 6 years-ASQ-SE2 Consent Form English

• From 6 years – 18 years–SDQ HUGS Consent Form English

SCREENING TOOLS

• ASQ Social & Emotional Screening for children 3 Months to 6 years- (*THESE WILL COME DIRECTLY TO HUGS FROM THE BELOW LINK)  Please click here

• SDQ (Strengths & Difficulties) Questionnaire for children 6 to 18 years. (THESE WILL NOT BE AUTOMATICALLY DELIVERED TO HUGS AND MUST BE PRINTED AND SENT TO HUGS or CALL TO REQUEST THE FORMS)  Please click here

AUTHORIZATION

• Release form (for release of information) This may be completed for a Doctor or other service provider but IS NOT MANDATORY.  Authorization to Release Information

Por favor, devuelva todas las formas abajo, por fax al 239-330-7163 – “Atención: HUGS”

FORMA DE CONSENTIMIENTO

• De 3 meses a 6 años-ASQ-SE2 Consent Form Spanish

• De 6 años a 18 años-SDQ HUGS Consent Form Spanish

CUESTIONARIO DE ASQ (SOCIAL EMOCIONAL)

• Haga un clic aquí 3 meses a 6 años

CUESTIONARIO DE SDQ (FUERZAS Y DIFICULTADES)

• Haga un clic aquí 6 anos a 18 años

Forma de Autorización Para Usar o Divulgar la Información Protegida de Salúd

• Authorization to Release Information Spanish