Forms - Unfold Psychology

Relationship History
Age At First Significant Romantic Relationship?*
Total Number Of Marriages / Long Term (Over 1 Year) Relationships*
If You Are Married / Partnered, Please Briefly Describe Your Relationship
If You Are Currenlty Single, Divorced, Separated Or Widowed, Please Briefly Describe Your Last Long Term Relationship

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Mental Health History
Have You Ever Sought Mental Health Treatment?
Yes
No
Please complete the following about your past (or present) treatment experience(s)
- Psychiatry Provider Name
- Provider Contact Info
- Approximate Dates
- Problem(s) Addressed?
- Was Treatment Helpful?
- Psychiatry Provider Name
- Provider Contact Info
- Approximate Dates
- Problem(s) Addressed?
- Was Treatment Helpful?
- Psychiatry Provider Name
- Provider Contact Info
- Approximate Dates
- Problem(s) Addressed?
- Was Treatment Helpful?
Have You Ever Been Hospitalized For A Psychiatric Condition?
Yes
No
Please describe the circumstances of your hospitalization (how long, name of facility, dates)
Have You Ever Been Admitted To Residential Or Intensive Outpatient Treatment?
Yes
No
Please describe the circumstances of your treatment (how long, name of facility, dates)
Do You Use Tobacco?
Yes
No
Please indicate the amount and frequency
How Many Beverages Containing Alcohol Do You Consume In A Typical Week?*
How Many Beverages Containing Caffeine Do You Consume In A Typical Day?*
Have You Used Any Drugs In The Past 30 Days That Were Not Prescribed By A Healthcare Professional (E.G., Marijuana, Hash, Cocaine, Adderall, Diet Pills, Ecstasy, Valium, Lsd, Acid, Mushrooms, Heroin, Vicodin, Codeine, Or Other)?*
Yes
No
Please describe (including the amount and frequency)
Has Anyone Ever Suggested You Drink Alcohol Or Use Drugs To Excess?*
Yes
No
Have You Ever Been In Treatment For Substance And/Or Alcohol Use?*
Yes
No
Please describe the circumstances of your treatment (how long, name of facility, dates)
Approximately How Many Hours Per Day Do You Spend Online?
- Social Networking Sites
- Hours*
- Youtube
- Hours*
- Gaming
- Hours*
- Browsing
- Hours*
- Shopping
- Hours*
- Shopping
- Hours*
- Gambling
- Hours*
- Pornography Sites
- Hours*
- Other
- Hours*
Do You Feel Your Technology Use Is Balanced?
Yes
No
Do You Ever Have Problems Controlling The Amount Of Food You Eat?
Yes
No
Please Describe
How Many Times Per Year Do You Gamble (Online Or Other)?*
Have You Ever Had Thoughts Of Harming Yourself?*
Yes
No
Please Describe The Types Of Thoughts (Including Frequency, Intensity And Duration)
Have You Ever Purposely Injured Yourself Without Suicidal Intent (E.G., Cutting, Hitting, Burning)?*
Yes
No
Please Describe The Types Of Behavior(S) (Including Frequency, Intensity And Duration)
In The Past Few Weeks, Have You Had Thoughts Of Suicide?*
Yes
No
Please Describe The Types Of Thoughts (Including Frequency, Intensity And Duration) And Whether You Have Acted on these thoughts
Have You Seriously Considered Suicide In The Past?*
Yes
No
Please Describe
Have You Ever Attempted Suicide?*
Yes
No
Please Describe
Have You Ever Seriously Considered Harming Another Person?*
Yes
No
Please Describe
Have You Ever Intentionally Physically Harmed Another Person?*
Yes
No
Please Describe
Do You Currently Have Thoughts Of Harming Another Person?*
Yes
No
Please Describe
Has Anyone In Your Family Attempted Or Committed Suicide?*
Yes
No
Please Describe
Do You Currently Have Access To Any Weapons, Including Firearms?*
Yes
No
Please Describe

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Legal History
Have You Ever Been Arrested Or Convicted Of A Crime?*
Yes
No
Please Describe (Including When)
Are You Presently Involved In A Lawsuit?*
Yes
No
Please Describe
Are You Seeking Treatment Due To An Accident Or Injury?*
Yes
No
Please Describe
Are You Required By A Court, The Police Or A Probation/Parole Officer To Be In Treatment?*
Yes
No
Please Describe

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Reflections
What Gives You The Most Pleasure In Your Life?*
What Are Your Main Worries Or Fears?*
What Are Your Most Important Hopes And Dreams?*
Other
Is There Anything Else You Would Like Your Healthcare Professional To Know?
Email
This field is for validation purposes and should be left unchanged.

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Patient Information Questionnaire

Step 1 of 9

Personal & Contact Information

Presenting Problem

Please Identify Any Of The Below That Are Of Concern At This Time (Please Check All That Apply)

Education & Work History

Family History

Medical History

History Of

Check One

Details and Dates

For Female Patients

Relationship History

Mental Health History

Approximately How Many Hours Per Day Do You Spend Online?

Legal History

Reflections

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