Online Teletherapy Consent and Intake Form

Personal Information

Full Name Date of Birth Address Email Phone Number

Emergency Contact

Contact Name Relationship Contact Phone Number

Therapy Information

Reason for Seeking Therapy / Presenting Issues Have you attended therapy before? Yes No Goals for Therapy

Teletherapy Consent

I acknowledge that I have read and understand the information regarding teletherapy services including potential benefits, risks, and confidentiality limitations, and I consent to participate in online therapy sessions.

Signature

Full Name (as signature) Date