Teletherapy Client Intake Form
First Name
Last Name
Date of Birth
Gender
Female
Male
Non-binary
Other
Prefer not to say
Email Address
Phone Number
Address
City
State/Province
ZIP/Postal Code
Preferred Contact Method
Email
Phone
Emergency Contact Name
Emergency Contact Phone
Relationship to Emergency Contact
Current Concerns or Reasons for Seeking Teletherapy
Relevant Medical or Mental Health History
Are you currently taking any medications?
Have you previously received therapy?
Yes
No
If yes, please describe
Is there anything else you would like your therapist to know?