Trauma Recovery Therapy Consent Form

Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Preferred Pronouns

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Preferred Contact Method

Emergency Contact Name

First NameMiddle NameLast Name

Emergency Contact Relationship

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Have You Received Prior Counseling or Therapy?

Current Therapist or Psychiatrist Name

Current Medications or Treatments Relevant to Therapy

Current Safety Concerns or Recent Crisis Concerns Relevant to Treatment

Main reason for seeking trauma recovery therapy

Type of trauma or concern to address

Primary goals for therapy

Preferred session format

Preferred session time or day

Accessibility or communication accommodations needed

Client Signature

Date Signed

Date