Patient: Teagan Epperson

Please use blue or black ink when filling out this admission form. Additional information from all but the patient must be initialled by the author. Please answer all questions to the best of your ability. For further information or guidance, please contact a member of St. Christina staff at the number provided
in our guide brochure.

Patient Full Name: EPPERSON, TEAGAN

Age: 16
DOB: 03/06/1995
Gender: Female
Address: Anne Elizabeth Shepherd Home; 751 Double Churches Road
City: Columbus
State: Georgia
Ethnicity: Caucasian
Height: 5 foot 5
Weight: 109 lb
Eye Color: Brown
Hair Color: Dirty blond
Distinguishing Marks: Pierced ears and a scar on my right thigh from falling when I was younger


Medical History:

Please list any and all allergies and age of onset below:
I’m allergic from everything from pollen to animals dander to penicillin. This all came around when I was about six.

Are you aware of any ongoing medical issues?:
My mom is constantly telling the doctors that I have asthma.

If yes, list age of diagnoses by medical professionals, or age of onset below:
I was first diagnosed with asthma when I was seven.

If you are receiving treatment for an ongoing medical complaint, please list prescriptions, strength of dose, frequency of dose, and other treatment plans below:
I take 5 mg of Singulair every morning and a ProAir inhaler as needed.

Do you smoke tobacco, consume alcohol, or use street drugs? If yes, please list number of packs per day, number of drinks per day and/or names of consumed drugs below:
I’ve never taken drugs or alcohol.

Although Teagan has gone to the doctor for these issues, after much testing, it has been confirmed that Teagan does not possess asthma or allergies to pollen, animals, and penicillin.



Psychiatric History:

Have you been diagnosed with any psychiatric issues? If so, please list diagnoses and age of diagnoses below:
Dr. Haleigh says that she has diagnosed me with Munchausen Syndrome by Proxy just a few months ago, but that I’ve had it since I was in Preschool. She said that means that nothing has ever been really wrong with me, but that my mom makes things wrong with me.

While talking with Dr. Haleigh, she has also told me that I have been sexually abused. I never looked at what happened to me in that way though.

If you answered yes to the above, please list any and all prescriptions, including dosage and frequency of dosage, and other treatment plans below:
A few weeks ago Dr. Haleigh was able to prescribe me 50 mg of Prozac for my anxiety which she tells me has come from my disorder as well as sexual abuse. She also has told me to stop taking the other medications I have been given for the illness that supposedly I don’t have.

If you answered yes to the above, please describe noted feelings, symptoms, triggers and incidents associated with the diagnoses, and ages of incidents below:
For as long as I can remember, I have gone to the hospital for a variety of reasons. When I was younger it started out as things from vomiting to ear infections to diaper rashes. They got better when my mom admitted me to the hospital, she said, though they always came back if not worse than before. Over the years, the reasons for me to go to the hospital never ceased. I felt horrible and ill every hour of every day when I was at home.

The most recent incident occurred only a few months ago. I had to be admitted to the hospital again with a temperature of 104 and my mom reported bloody stools to the doctors. A physical exam, urinalysis, and blood work all showed up normal. Other tests were given to me that was painful and I still showed up as normal. After five days the bleeding stopped and I was discharged from the hospital. None of this was unusual to me. It happened all the time: I get sick, I go to the hospital, nothing is wrong, I’m discharged. The hospital was like my safety place. But then the symptoms all came back for the follow up visit so I was admitted to the intensive care unit in another hospital. There were no problems and again I was discharged.

I went to a third hospital with the same issues again. This had been the first time I had been to a hospital three times in a month. A doctor recognized my mom and confronted her about my issue. After refusing to admit what she did at first, eventually she collapsed under the pressure and admitted to cutting her own legs and disconnecting my intravenous line while I was asleep to get blood for that she had me swallow without knowing it. Fortunately, Dr. Haleigh says, the doctors had confronted my mom in time, preventing a general surgical consultation that I was scheduled for. Shortly after, just a month ago actually, my mom has been sent to a rehabilitation center somewhere.

Regarding the sexual abuse, my older sister, Ellie, has always been close to me. She tries to make herself as close to me as she possibly can. While I wasn’t at the hospital and our mom wasn’t around, Ellie always convinced me to play a game with her. It was the same game every single time, Who Can Make the Other Wetter. No one ever one this game or at least we never decided on the winner. I never understood that this was a bad game or that other siblings didn’t play this game until Dr. Haleigh told me. I didn’t want to play, but Ellie was my best friend and I didn’t want to upset her. If I did, Ellie would hurt me until I got wet. I never told anyone before I started seeing Dr. Haleigh because I didn’t want her getting in trouble, I still love Ellie. Ellie has gone to live with our dad now that our mom’s at a hospital while I went to a Youth Services Center. She still writes me letters all the time and says we should meet up soon. Dr. Haleigh says that Ellie does this because our dad left my mom as soon as I was born and did this to me to assert her power.

Have you ever been hospitalized for these diagnoses? If yes, please provide facility name(s) and age of admissions and discharges:
I’ve been hospitalized at the very least three hospitals: Northeast Georgia Medical Center & Health System, Emory Johns Creek Hospital, and Northside Hospital. I’ve been admitted to one of these hospitals at the very least three times a year, but the last three times I went were in the same month about 3 months ago.

Are you aware of a history of psychiatric complaints in your family? If yes, please list family member(s), diagnoses, and how this affected you personally:
My mom has some kind of disorder that makes her seek attention; they’re trying to figure it out in the hospital that she was just recently sent to.



Environmental History:

Are you aware of any complications during your birth? If yes, please explain below:
Nothing during birth

Are you aware of any difficulties in development during your infancy, such as learning disabilities, speech impediments, etc? If yes, please explain below:
I believe I did everything at the right age

Are you aware of any long term separation from your mother during your infancy? If yes, please explain below:
I don’t believe I was away from her, but I don’t doubt she didn’t do something that sent me to the hospital a few times. Who knows?

Please describe the location and environment in which you grew up. Please list town and state, and what it was like and how this affected you:
I grew up all over Georgia, we moved around quite a few times. I don’t think it affected me in a big way though I wasn’t able to become close to anyone besides my mom and my older sister.

Please describe your educational history. How were you in school, both as a young child and in later grades? How were your grades? Did you enjoy school? Please answer below:
I had never been good at school because I preoccupied with everything that was going on at home from my older sister to being sick all of the time. This caused my grades to not be very good so no, school was not my favorite place to be.

Do/did you have many friends growing up? Do/did you have a best friend? If yes, please explain below:
My closest friend had always been Ellie. Also, I was too afraid to make friends with other people because I had always assumed that if anyone really knew how sick I was, they wouldn’t like me.

Do/did you pursue any extracurricular activities or talents? If yes, please explain below:
I was too sick to do anything if I wanted to. But I have always loved photography.

If sexually active, please list age of onset and sexual preference below. If not sexually active, are you aware of a sexual preference?:
I’ve never done anything except fool around with Ellie. I guess that would make me a lesbian? Though curious about guys? I’m not really sure.



Legal History:

Do/did you ever abuse controlled substances, including but not limited to prescription medications, street drugs or alcohol? If yes, please explain below:
I have never abused anything on my own. I am pretty sure that my mom has put drugs in my drinks or foods occasionally for a reason to bring me to the doctor.

Have you ever been convicted of a crime? If yes, please list conviction, age of conviction and circumstances below:
No I haven’t

If you answered yes to the above, please list sentences connected to these convictions below:
N/a

Have you ever knowingly committed a crime for which you were not convicted or sentenced? If yes, please explain below:
N/a



Personal Interview:

Describe yourself to the best of your ability in only five words:
Scared, Empty, Lost, Worried, Pained

Is the glass half empty, or half full? Explain your answer below:
My glass is probably half empty. My dad left before I was born, my mom hurts me in ways that I don’t even know the half of, and my older sister who I’ve always looked up to has screwed me up for the longest time. There’s nothing left for me.

If you could change only one thing in your life, what would it be, and why?:
I would change the pain that I’ve gone through. What my mom has done to me has screwed up my insides so I’m always hurting. It’s difficult to eat normal foods because it always threatens to come back up. Also, the fact that my mom would do this to me hurts to the point of depression.

How do you feel about your life and the things you have done in it, looking back? If you have committed crimes, how do you feel about those now?:
I regret what I’ve done with Ellie as much as I love her. I don’t feel like I can live without her though maybe if we hadn’t done what we did, my life would just be a little more normal. I know I can’t change what my mom has done to me though.

What are your goals in life, and how do you feel those would be best accomplished?:
My goal would be to get better. To be a normal person and to forget about what has happened to me in the past and make the best out of the life I still have. I would assume being at St. Christina’s could help me with that.

Lastly, why have you chosen admission at St. Christina Psychiatric Rehabilitation Center, and how do you think this will help you toward your life goals?:
I need to get better. My mom and sister have screwed me up. I want to live normally and if being there is the only way to do that, so be it. I’m depressed and I’m lonely and I hurt every day, I want to be helped. Not to mention I have nowhere to go except to my dad that I have never met and my sister who while continue to touch me.



Patient/Guardian Signature:

By agreeing to admission to our facilities, you hereby agree to abide by all rules and terms of service outlined in patient or resident handbooks, rules and codes of conduct. You hereby agree to waive your right to voluntary dismissal from our facilities until such a time as facility administrators sign paperwork for your release. You hereby agree to comply with facility staff recommendations, demands, or outlines for treatment. You hereby waive your right to informed medical consent before medication changes or medical procedures. You hereby agree to waive your right to hold GR Biotech and its Subsidiaries responsible for any personal harm or distress incurred during treatment. GR Biotech and its Subsidiaries reserve the right to add or amend these terms of service at any time.

Please sign and date below:

Dr. Winter Haleigh 05/20/2011
Teagan Epperson 05/23/2011