Trauma-Focused Therapy Consent and Intake Form

1. Client Information

Full Name Date of Birth Phone Number Email Address Address

2. Emergency Contact

Name Relationship Phone Number

3. Presenting Concerns

Please describe your main concerns or reasons for seeking trauma-focused therapy:

4. Mental Health History

Have you previously received any counseling, therapy, or psychiatric treatment? If yes, please provide details: Any previous mental health diagnoses? Previous hospitalizations related to mental health? If yes, please specify:

5. Trauma Experience

Are you comfortable sharing a brief description of your trauma experience(s)?

6. Current Symptoms

Please outline any current symptoms you are experiencing (e.g., anxiety, depression, insomnia, nightmares):

7. Physical Health

Please describe your general physical health: List any current medications:

8. Substance Use

Do you currently use alcohol, tobacco, or other substances? If yes, please specify:

9. Consent & Agreement

I have read and understand the information about trauma-focused therapy, its nature, possible benefits, and risks. I freely consent to participate and understand my participation is voluntary.

I agree to participate in trauma-focused therapy and provide accurate information.

Client Signature Date