Teletherapy Session Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact
Contact Name
Relationship
Phone Number
Teletherapy Details
Preferred Method of Teletherapy
Video Call
Phone Call
Text/Chat
Have you previously attended therapy?
Yes
No
Reason for seeking teletherapy
Goals for therapy
Anything else you'd like your therapist to know