Schedule Appointment
1186 Hwy 45 Bypass, Suite D, Jackson TN 38301
731-215-0502
Text Us
Email Us
Form Submission is restricted
Form is successfully submitted. Thank you!
Client Check-In
Required fields are marked with an asterisk *
Are you a new or existing client? (BE PATIENT AS THIS PAGE IS SOMETIMES SLOW TO RESPOND. Thanks!!)
*
New Client
Existing Client
Client's First Name
*
Client's First Name
Client's Last Name
*
Client's Last Name
At times we may have college interns working with us as a part of their college degree. Are you will to have an intern participate in your sessions?
Yes I consent to have an intern participate in my session.
No I do not consent to have an intern participate in my session
At times we may have a therapy dog (currently in-training). Do you wish to meet our therapy dog?
Yes I consent to meet the therapy dog and understand the potential risks.
No I do not consent.
Do you need to update your contact information or insurance?
*
No
Address
Telephone
Email
Insurance
1
2
3
4
5
6
7
8
9
10
11
12
DOB: Month
*
Date of Birth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
DOB: Day
*
Date of Birth
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
DOB: Year
*
Date of Birth
Gender
*
Male
Female
Guardian's Name
First and Last Name (IF the client is a minor)
Street Address
*
City
*
Tennessee
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
*
Zip Code
*
Phone
*
Number format 1234567890
Email
I would like to receive email appointment reminders:
*
Yes
No
I would like to receive email updates and information from LifeWorks Resources:
*
Yes
No
Self Pay
Aetna
Amerigroup
Beacon Health Options
BCBS
Blue Care
Cigna
Cover Kids
EAP
United Healthcare
United Healthcare Community Plan
Value Options
Other
Insurance Name
*
Insurance Name (Other)
*
Type Insurance Name Here
Insurance ID Number
*
Did you sign our informed consent document online before coming today?
*
Yes
No
LifeWorks Resources LLC would like to offer you the ability to receive automated text and voice messages (SMS)reminders for your appointments. Messages are generated by our Electronic Health Records, however they are transmitted over a public network to a personal phone. I understand that this service is offered free of charge. However, standard text messaging rates from my mobile carrier may apply. Please select either "agree" or "disagree" to give your consent:
*
Agree
Disagree
Street Address (click to type)
*
City
*
Tennessee
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
*
Zip Code
*
Phone
*
Number format 1234567890
Email
Self Pay
Aetna
Amerigroup
Beacon Health Options
BCBS
Blue Care
Cigna
Cover Kids
EAP
United Healthcare
United Healthcare Community Plan
Value Options
Other
Insurance Name
*
Insurance Name (Other)
*
Type Insurance Name Here
Insurance ID Number
*
What is your current employment situation? Check all that apply:
Student
Employed and Satisfied
Employed but Dissatisfied
Unemployed
Coworker Conflicts
Supervisor Conflicts
Unstable work history
Disabled
In The Past 30 days:
Sad/Depressed Mood
None
Mild
Moderate
Severe
Irritability
None
Mild
Moderate
Severe
Trouble Concentrating
None
Mild
Moderate
Severe
Withdraw From and/or Avoid People
None
Mild
Moderate
Severe
Loss of Energy
None
Mild
Moderate
Severe
Low Self-Esteem / Feeling Worthless
None
Mild
Moderate
Severe
See Future as Hopeless
None
Mild
Moderate
Severe
Thoughts of Suicide or Death
None
Mild
Moderate
Severe
Feeling Nervous / Scared
None
Mild
Moderate
Severe
Tense / Agitated / On Edge
None
Mild
Moderate
Severe
Worrying About Things
None
Mild
Moderate
Severe
Stressed
None
Mild
Moderate
Severe
Frustrated
None
Mild
Moderate
Severe
Rapid Heart Rate
None
Mild
Moderate
Severe
Shortness of Breath
None
Mild
Moderate
Severe
Mood Swings
None
Mild
Moderate
Severe
Anger
None
Mild
Moderate
Severe
Do you feel stress - tense, restless, nervous, or anxious, or unable to sleep at night because your mind is troubled all the time - these days?
Not at all
Only a little
To some extent
Rather much
Very much
declined to specify
Are you now married, widowed, divorced, separated, never married or living with a partner?
Married
Widowed
Divorced
Separated
Never married
Living with partner
Declined to answer
In a typical week, how many times do you talk on the telephone with family, friends, or neighbors?
Enter a number
In a typical week, how often do you get together with friends or relatives?
Enter a number
In a typical year, how often do you attend church or religious services?
Enter a number
Do you belong to any clubs or organizations such as church groups unions, fraternal or athletic groups, or school groups?
Yes
No
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
Yes
No
Within the last year, have you been afraid of your partner or ex-partner?
Yes
No
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
Yes
No
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?
Yes
No
Which - if any - of these substances do you currently use or have used in the past? Please use the box to indicate your age at first use and age at last use. (E.g.: Alcohol - 16, 30)
None
Alcohol
Xanax
Pain pills
Amphetamines (Riatlin, etc)
Caffeine
Cocaine
Marijuana
Inhalants
Please use this box to indicate your age at first use and age at last use. (E.g.: Alcohol - 16, 30)
Changes in symptoms since last appointment:
Sad / Depressed Mood
Worse
No Change
Improved
N/A
Irritability
Worse
No Change
Improved
N/A
Trouble Concentrating
Worse
No Change
Improved
N/A
Withdraw from / Avoid People
Worse
No Change
Improved
N/A
Loss of Energy
Worse
No Change
Improved
N/A
Low Self-Esteem / Feeling Worthless
Worse
No Change
Improved
N/A
See Future as Hopeless
Worse
No Change
Improved
N/A
Thoughts of Suicide or Death
Worse
No Change
Improved
N/A
Feeling Nervous / Scared
Worse
No Change
Improved
N/A
Feeling Tense / Agitated / On Edge
Worse
No Change
Improved
N/A
Worrying about Things
Worse
No Change
Improved
N/A
Stressed
Worse
No Change
Improved
N/A
Frustrated
Worse
No Change
Improved
N/A
Rapid Heart Rate
Worse
No Change
Improved
N/A
Shortness of Breath
Worse
No Change
Improved
N/A
Mood Swings
Worse
No Change
Improved
N/A
Anger
Worse
No Change
Improved
N/A
Submit
