Adult Psychosocial History and Informed Consent
The purpose of this questionnaire is to obtain a comprehensive understanding of your life experiences and background. Completing these questions as fully and as accurately as you can will benefit you through the development of a treatment program suited to your specific needs.

Please allow for 10-15 minutes of UNINTERRUPTED time to complete this questionnaire prior to your first scheduled appointment. Please note that for your security, you will be timed out if you leave your computer for any extended period of time. Once submitted, this information comes only to Connect staff and is not ever shared with any other entity without your expressed written consent.

Please indicate the Connect PS Clinician you will be working with: *
How did you find out about Connect PS? *
Check all the apply
Required
Contact Information
Person completing form on your behalf *
First and Last Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Home Address *
e.g., 1234 Park St; The Woodlands, TX 77380
Your answer
Best Contact Phone Number *
Your answer
Best Contact Email *
Your answer
Secondary Contact Phone Number
Your answer
Secondary Contact Email
Your answer
Marital Status *
Names, ages, relationship to you of those significant to your life: *
e.g., Sam (45) husband
Your answer
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