Royce Mayer

Please use blue or black ink when filling out this admission form. Additional information from all but the patient must be initialed 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: Mayer, Royce

Age: 16
DOB: 10/28/1994
Gender: Male
Address: 17 East Judas Drive
City: Ruffler
State: Virginia
Ethnicity: Caucasian
Height: 4’10’’
Weight: 82 Lbs
Eye Color:Green
Hair Color:Black
Distinguishing Marks: Tattoos of handcuffs on each wrist.


Medical History:

Please list any and all allergies and age of onset below:
None
Are you aware of any ongoing medical issues?:
No

If yes, list age of diagnoses by medical professionals, or age of onset below:


If you are receiving treatment for an ongoing medical complaint, please list prescriptions, strength of dose, frequency of dose, and other treatment plans below:
None

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:
None



Psychiatric History:

Have you been diagnosed with any psychiatric issues? If so, please list diagnoses and age of diagnoses below:
Dependent Personality Disorder-Four years old.
Post-Traumatic Stress Disorder- Five months ago.

If you answered yes to the above, please list any and all prescriptions, including dosage and frequency of dosage, and other treatment plans below:
Prozac-20mg

If you answered yes to the above, please describe your feelings, symptoms, triggers and any incidents associated with the diagnoses, such as outbursts, suicide attempts or any other signs of non-typical behaviors, and approximate ages of incidents below:
I feel sick to my stomach and almost physical pain whenever I am not with one of my ‘persons’. (My ‘persons’ are people I choose that I want to be around I only have one or two at a time.”

Have you ever been hospitalized for these diagnoses? If yes, please provide facility name(s) and age of admissions and discharges as well as what diagnoses you were you hospitalized for, or what incidents lead to hospitalization:
No.

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:
No.



Environmental History:

Are you aware of any complications during your birth? If yes, please explain below:
No.

Are you aware of any difficulties in development during your infancy, such as learning disabilities, speech impediments, etc? If yes, please explain below:
Yes, I would not talk to anyone except my mother and father until I was 8.

Are you aware of any long term separation from your mother during your infancy? If yes, please explain below:
No.

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 lived in a suburban home, we were not wealth but not poor, I never missed a meal due to money issues.

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? What was school socialization like? What were your academic strengths and weaknesses? Please answer below:
I have As in all my classes except math, which is an F, because I would not ever ask questions when I was confused and that hindered my learning.I hate school.

Do/did you have many friends growing up? Do/did you have a best friend? If yes, please explain below:
Yes, I had one named Ricky Rodriguez. He was my best and only friend.

Do/did you pursue any extra curricular activities or talents? If yes, please explain below:
No…Er, yes I was in the reading club for one year.

If sexually active, please list age of onset and sexual preference below. If not sexually active, are you aware of a sexual preference?:
I am not sexually active but I am attracted to men.

Please explain a little about your overall life below. What circumstances do you feel have brought you to where you are now? How do you feel about those? Do you have any thing else to note about your life that you feel has had some bearing on your current situation? Please explain below:
I, well in school I was a very goo kid but I hated all the teachers and all the students, they were not people I wanted to associate with, but Ricky, he was one that I did want to talk to. Six months ago, Ricky stopped seeing me, he won't answer when I call his phone number and I can't find him. Maybe if I get better he won't hide anymore...


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:
NO!

Have you ever been convicted of a crime? If yes, please list conviction, age of conviction and circumstances below:
NO! [Dr. Greskof: Six months ago in a fit of fear and confusion, Royce killed his only friend Ricky. To this day he believes that Ricky his hiding from him and that he has done something to offend Ricky. At this period in time, we have been letting him believe that seeing as he is unstable.]

If you answered yes to the above, please list sentences connected to these convictions below:
No, No, NO! [Dr. Greskof: For the past six months Royce has been in Rutherford juvenile detention center.]

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



Personal Interview:

Describe yourself to the best of your ability in only five words:
The cute gay kid Royce.

You come across a glass of water. The total volume of water in the glass constitutes half of its total capacity. Is the glass half empty, or half full? Explain your answer below:
Who poured the glass?

If you could change only one thing in your life, what would it be, and why?:
I would make the people I don’t like go away.

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 feel the few things I’ve done were simple and good.

What are your goals in life, and how do you feel those would be best accomplished?:
My goal is to adopt a child I like and raise her nicely.

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 want Ricky back!


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:

Royce Mayer 06/22/2011

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Player Nickname: Brian
Chatango Screename: brianhri
Character Play-ByCameron Ugh