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LifeQuest Adult Intake Form
LifeQuest Adult Information Form
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LifeQuest Adult Intake Form
Please complete and submit the following Intake Form
RM_Stats
Username
*
Password
*
Password must be at least 7 characters long.
Enter password again
*
Password must be at least 7 characters long.
Email
*
Date
*
First and Last Name
*
Address and Street
*
City,State, Zip
*
Telephone
*
Ok to leave a voice mail at this number?
*
Yes
No
Current Occupational Status
Full Time
Part Time
Self-employed
Student
Do You Have Insurance?
*
Yes
No
If you have insurance, please select your Insurace company
Select an option
United HealthCare
United Behavioral Health
Anthem Blue Cross Blue Shield
Cigna
Magellan
Magellan EAP
Coventry
MOHealthNet
MissouriCare
Aetna
Aetna Better
HealthLink
Other
Current Concerns:
Rate yourself on the following questions below using a scale of 1- 5 (1=mild - 5 =severe)
What is your stress level?
*
None
1
2
3
4
5
What would you say is your anger level?
*
None
1
2
3
4
5
What is your patience level - (1) being good
*
1
2
3
4
5
No Patience
What is your frustration level?
*
None
1
2
3
4
5
Rate your level of unresolved emotional pain caused by others
*
None
1
2
3
4
5
Do you feel that you may be harboring unforgiveness toward anyone?
*
Yes
NO
Spiritual Area:
Do you believe in God?
Yes
No
Not sure anymore
Behavior - Check any of the following behaviors that apply to you.
*
Overeat
Insomnia
Work too hard
Suicidal attempts
Vomiting
Lack of motivation
Outbursts of temper
Can't keep a job
Drink too much
Sleep disturbance
Loss of control
Crying
Concentration difficulties
Panic attacks
Compulsions
Feelings - Check any of the following that apply to you
*
Angry
Conflicted
Energetic
Guilty
Restless
Fearful
Depressed
Hopeful
Tense
Annoyed
Regretful
Envious
Anxious
Lonely
Helpless
Physical Symptoms - Check the following that apply to you
*
Headaches
Dry Mouth
Sexual Disturbances
Bowel Disturbances
Stomach Trouble
Palpitations
Tremors
Hear Things
Numbness
Fatigue
Don't like being touched
Unable to Relax
Hallucinations
Check any of the following that apply to you
Marijuana
*
Select an option
Never
Rarely
Frequently
Very often
Tranquilizers
*
Select an option
Never
Rarely
Frequently
Very often
Sedatives
*
Select an option
Never
Rarely
Frequently
Very often
Cocaine
Select an option
Never
Rarely
Frequently
Very often
Painkillers
*
Select an option
Never
Rarely
Frequently
Very often
Alcohol
*
Select an option
Never
Rarely
Frequently
Very often
Coffee
*
Select an option
Never
Rarely
Frequently
Very often
Cigarettes
*
Select an option
Never
Rarely
Frequently
Very often
Narcotics
*
Select an option
Never
Rarely
Frequently
Very often
Stimulants
*
Select an option
Never
Rarely
Frequently
Very often
Never, Rarely, Frequently, Very often
Hallucinogens
*
Select an option
Never
Rarely
Frequently
Very often
Compulsive Exercise
*
Select an option
Never
Rarely
Frequently
Very often
Use Laxatives
*
Select an option
Never
Rarely
Frequently
Very often
Early Morning Wakening
*
Select an option
Never
Rarely
Frequently
Very often
Binge/Purge
*
Select an option
Never
Rarely
Frequently
Very often
Lack of Interest in Activities
*
Select an option
Never
Rarely
Frequently
Very often
High Blood Preasure
*
Select an option
Never
Rarely
Frequently
Very often
Allergies
*
Select an option
Never
Rarely
Frequently
Very often
Fitful Sleep
*
Select an option
Never
Rarely
Frequently
Very often
Poor Appetite
*
Select an option
Never
Rarely
Frequently
Very often
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
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