Trauma-Informed Christian Counseling Intake Form

Personal Information

Full Name Date of Birth Phone Number Email Address Address

Emergency Contact

Name Relationship Phone Number

Faith & Community

Describe your faith background Do you have a church home? Yes No If yes, what is the name of your church?

Presenting Concerns

What brings you to counseling? Are you seeking support related to trauma? Yes No Unsure If yes or unsure, please describe (as much as you feel comfortable):

Mental & Physical Health

Any history of mental health concerns? Current medications Physical health concerns

Additional Information

What are your goals for counseling? Have you received counseling before? Yes No Anything else you would like to share: