LifeQuest Adult Information Form

Please complete and submit the Adult Information Form

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Username^*

Password^*

Password must be at least 7 characters long.

Enter password again^*

Password must be at least 7 characters long.

Email^*

Date:^*

Name:^*

Date of Birth:^*

MEDICAL HISTORY

Primary Care Physician:^*

If you don't have a Primary Care Physician please enter "none"

Physician's Address:

Please include full address and zip. If you do not have a Primary Physician, please enter "none"

Consent: Many managed care companies require that we have interaction with the client's physician to coordinate care. Do you give us consent to discuss your care with the above named doctor?^*

Date of your last medical evaluation:

Current medication(s) being taken: Please list here, if none please list "none"^*

Have you ever been hospitilized for medical or psychiatric reasons?^*

If Yes, please enter date(s)

Do you use recreational drugs?^*

If Yes, list the type of drug(s)

If No, when did you stop?

Do you drink alcohol?^*

If Yes, please list type of alcohol?

If you drink alcohol, list how much and how often.

Do you smoke cigarettes?^*

Do you use any other forms of tobacco?^*

Describe any important medical history, chronic ailments, or other health problems you experience, if none write "none"^*

Describe any other health problems or important medical history about your immediate family members and close relatives, including cronic ailments, if none write "none"^*

Do you have close relatives (father, mother,grands) who have experienced depression,anxiety, or other emotional difficulties? If yes, list the relation and the condition below, if none write "none"^*

SCHOOL AND FAMILY HISTORY

Did you experience any developmental, academic or behavior problems as a child or while in school, with peers or teachers? If so briefly list here, If none write "none"^*

What was the last year of school completed?^*

How would you describe your current support network? (friends, relatives, etc.)^*

Information which applies to your biological parents

Mother^*

Living
Deceased
Married
Divorced
Remarried

Father^*

Living
Deceased
Married
Divorced
Remarried

Do you consider someone else (step-parent, grandparent, etc.) to be one or both of your "real parents"?^*

If Yes, whom?

Describe your relationship with your mother while growing up:^*

Briefly describe your current rlationship with your mother^*

Describe your relationship with your father while growing up:^*

Briefly describe your current rlationship with your father:^*

Did you experience any family problems which occurred while growing up relating to alcohol or drug abuse?^*

Did you experience any family problems which occurred while growing up relating to sexual/physical/emotional abuse?^*

Marital Status:^*

MENTAL STATUS

Please check all of the following that describes how you've been feeling lately:^*

Sad
Anxious
Depressed
Frightened
Guilty
Angry
Ashamed
Aggressive
Resentful
Worthless
Tearful
Confused
Extreme ups/downs
Jealous
Helpless
Irritable

What activities or hobbies do you participate in?^*

Do you participate in regular exercise?^*

Have you had any change in sleeping habits?^*

Have you had any changes in eating habits?^*

Have you ever considered suicide in relation to your current issue?^*

Have you considered suicide in the past?^*

Have you had any homocidal thoughts recently or in regard to your current issue?^*

LEVEL OF FUNCTIONING: Please list any current impediments or problems in daily psychological, social or occupational functioning (i.e. isolation from friends, family, significant difficulty getting to work or completing tasks, financial strain, recent divorce, problems at work, etc.)^*

THOUGHTS: Please check all that apply to you.^*

I sometimes hear voices even though no one is nearby
I sometimes feel that forces outside of me control me
I sometimes feel that other people control my thoughts
I sometimes have the same thoughts over and connot control it
I sometimes feel that someone is out to hurt me or is against me
I am sometimes unable to control my behavior
None of the above

Is there any other information regarding you or your family that you would like to share with your counselor not already included? If, so please add below

Please list your goals for counseling^*

Privacy and Consent Regulations

LifeQuest Christian Counseling and its counselors and staff follow HIPPA laws and regulations in maintaining privacy – Based upon The Health Insurance Portability and Accountability Act of 1996 (HIPAA), the counselor/provider is required by law to maintain the privacy of protected client information and to provide and abide by this notice of its legal duties and privacy practices.
Before LifeQuest can provide services, each client is required to complete the Adult Intake Form, the Adult Information Forms, the Consent to Treat Form, and the HIPPA Receipt acknowledging that you were provided HIPPA rules and regulations regarding your rights concerning how we will use your information.  The Adult Intake and the Adult Information Forms are provided online in order to expedite the preparatory process before counseling begins.  If you would prefer we send you these Forms by email so that you may print, complete and bring them with you at your scheduled appointment, please complete the contact form and let us know.  You will be provided the HIPPA Regulations, HIPPA Receipt and Consent to treat Forms when you come for services.
We are committed to ensuring that your information is secure. Your information provided on these Forms will not be shared with any third parties without your written consent. In order to prevent unauthorized access or disclosure we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online.
LifeQuest Christian Counseling Services has taken significant steps to ensure the confidentiality and privacy of online communications, these steps in whole or in part, cannot guarantee the security of internet transactions. As such: I agree to release and indemnify LifeQuest Christian Counseling Services, Inc., from suits, claims, and other actions originating from information provided to us by completing the Adult Intake, and/or the Adult Information Form and submit said Forms to LifeQuest Christian Counseling Services, Inc.

I Accept

THANK YOU!

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