Teletherapy Intake Assessment

Personal Information

Full Name Date of Birth Email Address Phone Number Address Preferred Method of Contact Email Phone Video Call

Emergency Contact

Contact Name Relationship Phone Number

Medical & Mental Health History

Primary Concern(s) Current Medications Previous Therapy Experience Yes No If yes, please describe Relevant Medical Conditions

Teletherapy Preferences

Preferred Session Frequency Weekly Biweekly Monthly Best Days and Times for Sessions Any Additional Notes or Accommodations