Unbound form

First name *General Information

Last name *

Date of Birth *

Month

Day

Year

Email *

Gender *

MaleFemale

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

Have you had an appointment at Unbound in the past? * *

YesNo

Marital Status *

Do you have any children? *

YesNo

Are you interested in receiving *

Are you requesting *

An in office appointment A video chat appointment

How do you view God? *Connection to God

How do you view yourself in relationship with God? *

Do you have concerns with your connection to God? *

Are you currently seeing a therapist/counselor? *

YesNoTreatment and Medical History

Have you been in therapy before or received any prior inner healing assistance in the past? *

YesNo

Have you received a medical/psychiatric diagnosis? *

YesNo

Are you currently taking any psychiatric medications? *

YesNo

Is there a family history of substance abuse or mental illness in your family?

YesNo

Have you ever been treated for alcohol or drug use or abuse?

YesNoSubstance Use

Are you currently employed? *

YesNoWork History

Does your current employment or unemployment satisfy you? Please explain. *

Why would you like to receive an appointment? *

When did you notice the problem begin? *

Additional Comments:Treatment Expectations

Gender *

Have you had an appointment at Unbound in the past? * *

Do you have any children? *

Are you requesting *

Are you currently seeing a therapist/counselor? *

Have you been in therapy before or received any prior inner healing assistance in the past? *

Have you received a medical/psychiatric diagnosis? *

Are you currently taking any psychiatric medications? *

Is there a family history of substance abuse or mental illness in your family?

Have you ever been treated for alcohol or drug use or abuse?

Have you ever been: *

Are you currently employed? *

Please select any of the following that currently applies to you *

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