Trauma-Informed Care Intake Form

Personal Information

Full Name Date of Birth Contact Number Email Address Address Preferred Method of Contact Phone Email Text Message

Emergency Contact

Name Relationship Contact Number

Presenting Needs or Concerns

What brings you here today? What do you hope to achieve with support?

Trauma History

Are you comfortable sharing any experiences that have impacted your well-being? How have these experiences affected your daily life? What has been helpful for you in trying to cope?

Health & Wellness

Are you currently taking any medications? Physical Health Concerns Mental Health Concerns

Supports & Resources

Supportive Relationships (family, friends, community) Current Services / Other Professionals Involved

Preferences

Do you have any needs, accommodations, or practices that will help you feel safe and supported? Preferred Name / Pronouns Other Preferences