Keillor, Ellen

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
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Patient Full Name: Keillor, Ellen

Age: 17
DOB: 08/02/1994
Gender: Female
Address: 332 south Lavaca street
City:[/b Port Lavaca
[b]State: Texas
Ethnicity: Caucasian
Height: 5'5"
Weight: 125
Eye Color: Green
Hair Color: Red
Distinguishing Marks: Both ears of pierced, there are various scares on her legs and arms.


Medical History:

Please list any and all allergies and age of onset below:
Tree nuts.
Peanuts.

Are you aware of any ongoing medical issues?:
No

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

If you are receiving treatment for an ongoing medical complaint, please list prescriptions, strength of dose, frequency of dose, and other treatment plans below:
N/A

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:
N/A



Psychiatric History:

Have you been diagnosed with any psychiatric issues? If so, please list diagnoses and age of diagnoses below:
Yes, Victim of sexual and Physical abuse, resulting in Major Depressive Disorder, and violent tendency's. She was diagnosed when she was 16.
If you answered yes to the above, please list any and all prescriptions, including dosage and frequency of dosage, and other treatment plans below:
escitalopram 5 mg twice a day

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:
Well, the problem is it didn't seem to have any effect, except for when she attempted to take her own life. Normally she would hurt others, this is the first time she tried to kill herself.

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, unless you count her stay at the hospital after she swallowed her bottles of pills about a month 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:
No, not that I know of.



Environmental History:

Are you aware of any complications during your birth? If yes, please explain below:
She was born about a week late, but besides that, no.

Are you aware of any difficulties in development during your infancy, such as learning disabilities, speech impediments, etc? If yes, please explain below:
She has a lisp. When she first started talking I noticed it, and I told my daughter, her mother.

Are you aware of any long term separation from your mother during your infancy? If yes, please explain below:
There was about three years when she was one-three. You see her mother was young, only 18 when she was born. So she left Ellen with us, and she went off to college, but in the end her mother dropped out.

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:
Well we raised her till she was three here in Port Lavaca here in texas. It's a nice place. Theres plenty of young family's here and all. Her mother then moved her to austin texas till we got her again when she turned 16. From what I can gather out of her they didn't live in the greatest part of the city, but they weren't in the geto.

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:
Well when she first started she didn't hate school, but she didn't love it. It wasn't till she was in about sixth grade. That was when her mother started to date Alex. He would eventually become her step father. Now that I think of it, she was probably trying to get away from Alex. Any way for some one who loved going to school, she would get horrible grades. D's and C's. Except in choir, and drama. She would always get good parts in plays, not the lead, but some good parts. But she would get into fights if it wasn't during drama season. Mostly with guys.

Do/did you have many friends growing up? Do/did you have a best friend? If yes, please explain below:

She hung out with two other girls that she met through the theater department. Lets see, there was Margaret Chou, she was a musician in the pit, and Emily French, who was in the make up department.

Do/did you pursue any extra curricular activities or talents? If yes, please explain below:

She was in choir as a lead alto, and she was into drama.

If sexually active, please list age of onset and sexual preference below. If not sexually active, are you aware of a sexual preference?:

Well, I guess technically she was. But I don't think she's attracted to any one. I think she's afraid after what happened with her step dad.

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:
My grandma wanted me to fill out this part. What got me here? My mothers piss poor taste in men. I feel like crap. As for anything to note, heres a note, I hope you fall off a cliff.



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 she hasn't unless you count the attempt of suicide.

Have you ever been convicted of a crime? If yes, please list conviction, age of conviction and circumstances below:
No, luckily no one pressed charges when she got into fights with boys at school. As for when her step father tried to take her to court her on charges of assault the judge threw it out.

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:
Yes, she's gotten into several fights.



Personal Interview:

Describe yourself to the best of your ability in only five words:

Again, its Ellen, grandma's making me do this...lets see five words. Annoyed, sarcastic, angry...have I mentioned annoyed? bored.

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:

Neither, its full of air and water.

If you could change only one thing in your life, what would it be, and why?:
Answer Here

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?:

You know what, I feel fine with the things I've done.

What are your goals in life, and how do you feel those would be best accomplished?:

Goals? What type of goals should I have? You know what, my goal is to leave this stupid state and go far away. And all that takes is a plane ticket.

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 believe my grand daughter needs help, and I'm afraid Me and my husband can't give it to her. I just want her to be better.



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:

Elizabeth Keillor 08/19/2011

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Player Nickname: Summer
Chatango Screename:Sumertime1993
Character Play-ByAlison Sudol