Forms

This form is confidential and is designed to help your healthcare professional organize and gather information about you, your history, and the concerns that have led you to seek treatment. Please fill out as much as you are able. If, for any reason, you would rather not answer certain questions, feel free to leave them blank or write in “need to discuss.” Thank you.
Personal & Contact Information
Name*
First Last
SSN*
DOB*
Gender*
Address*
Street Address City State ZIP Code
Receive Mail
- Okay to receive mail here?
Home Phone*
Okay to phone
- Okay to phone
Okay to leave message
- Okay to leave message
Preferred Email Address*
Enter Email Confirm Email
(Please note that email is not a secure, never send your personal details to the office via email.)
Preferred Method of Contact
- Cell Phone
- Home Phone
- Email
- Mail
- Other
How did you hear about Unfold Psychology?
- Cell Medical Referral
- Website
- Psychology Today
- Presentation
- Friend or Family
- Mental Health Referral
- Other
Relationship Status*
Sexual Orientation*
Race / Ethnicity*
Language(s) Spoken*
Religious Or Spiritual Affiliation*
Are You Currently Active In Your Religion?*

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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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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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Personal & Contact Information