Trauma-Informed Teletherapy Intake Form
Client Information
Full Name
Date of Birth
Contact Number
Email Address
Mailing Address
Emergency Contact Name
Relationship
Emergency Contact Phone
Teletherapy Consent
I consent to participate in teletherapy sessions with my provider.
Yes
No
Presenting Concerns
Please describe your reason(s) for seeking therapy at this time
What are your goals for therapy?
Trauma and Safety
Would you like to share any information about past traumas or difficult experiences?
Do you currently feel safe? (If no, would you like to discuss a safety plan?)
Yes
No
If you'd like, please describe any safety concerns
Previous Therapy or Medical History
Have you previously seen a therapist or counselor?
Yes
No
If yes, please provide details (when, for how long, helpful or unhelpful experiences)
Current medications (if any):
Current or previous medical conditions:
Support System and Self-Care
Who are your main supports (friends, family, community)?
What helps you feel calm or supported when you're upset or overwhelmed?
Additional Information
Are there accommodations that would help you feel safer or more comfortable during teletherapy sessions?
Anything else you'd like your therapist to know?