Trauma-Informed Intake Form
Personal Information
Full Name
Date of Birth
Email
Phone Number
Address
Emergency Contact
Name
Phone Number
Relationship
Current Supports
Who is part of your support network?
Other healthcare providers involved in your care (names, roles):
History & Needs
Please describe the main concerns you'd like support with at this time:
Have you previously worked with a therapist or counselor about trauma?
Yes
No
Are there any topics, words, or situations you would like us to avoid or be mindful of?
Do you need any specific accommodations to feel safe and supported?
What would you like to accomplish in our work together?