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Patient Application Template

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Patient Application Template

Post by Admin Ghost on Sun Oct 09, 2011 10:54 pm

BEFORE YOU BEGIN

Before you begin your application, make sure that you have read all of the provided rules, guides and information in the required reading section. Failure to do so may result in your application being denied by STC staff.

When you post your application, don't forget to post it in the application process board, titled with your character's firstname and lastname. Please do not include any nicknames. Use the code provided to you at the bottom of this page, and fill in the appropriate fields.

Please do not edit the application code in any way, and please avoid using colours that may make it difficult to read.

Please read the application through from start to finish before you begin to fill it out, so that you can plan out how you are going to tackle it, and to make sure that you have your story in order. Please resist the temptation to add in details or events at the last minute, unless you are willing to go back and include them and their effects in the rest of the application. Last minute additions are a frequent cause for application pends, so be aware, and be consistent.

And over all, have fun with the application! this is the most important piece of writing you will do on this site, as it dictates the character you will be getting to play with from here-on out. And don't forget, even though we have an out of character section, this will not help them get into the institute. The in character application itself must be severe enough for them to be accepted.







◦ FIRSTNAME LASTNAME ◦

Small Image of your Character Play-By Here, in IMG tags.

________________________________________________________________________


D.O.B: dd/mm/yyyy
AGE: 14-17
GENDER: M/F
STREET ADDRESS: House Number & Street
TOWN/CITY: Town or City
STATE: County, or US State
HEIGHT: In feet & Inches
WEIGHT: In Pounds
ETHNICITY: Caucasian/Hispanic/Asian, etc
DISTINGUISHING MARKS: Any other distinguishing marks such as birth marks, moles, piercings and tattoos.


________________________________________________________________________

◦ MEDICAL HISTORY ◦

Do you have any ongoing medical issues for which you require treatment or medication?:

ANSWER HERE

Are you aware of any allergies? If so, please list allergy, age of onset and any medications or treatments you require or recieve:

ANSWER HERE

Have you had any surgeries or invasive procedures in the past? If yes, please list reason and approximate age of procedure:

ANSWER HERE

Do you take any medications or supplements daily? Do you follow any treatment plans? Please list medications or treatments, and reasons below:

ANSWER HERE

Do you use tobacco, consume alcohol, or use any other drugs including street drugs and/or prescription medications not prescribed to you? If yes, please list number of packs a day, number of drinks a day, and/or drugs consumed below:

ANSWER HERE


________________________________________________________________________

◦ PSYCHIATRIC SCREENING ◦

Please describe, to the best of your ability, your emotional and mental state of wellbeing:

ANSWER HERE

Have you been diagnosed with any psychiatric or psychological ailments? Please list any diagnoses below, and any treatments or medications prescribed to you. Please include name of medications, dosage, and number of doses per day:

ANSWER HERE

Have you ever been hospitalised or referred to regular outpatient care due to these ailments or associated incidents? If so, please note where, and at roughly what age:

ANSWER HERE

How have these ailments affected you and your life? Are there any major life instances you feel have been directly affected by these ailments, such as suicide attempts, criminal activities, etc?:

ANSWER HERE

What is your social life like? Do you have many friends or relationships? How are your family relationships?:

ANSWER HERE

Do you believe your life circumstances have contributed to any ailments? If so, what circumstances, and why do you feel they have contributed?:

ANSWER HERE

If you could change one past event that has happened to you, what would it be, and why?:

ANSWER HERE

Do you wish to rehabilitate from your ailment(s)? If so, how do you feel this would best be accomplished?:

ANSWER HERE

________________________________________________________________________

◦ ENVIRONMENTAL HISTORY ◦

Where did you grow up? Please list the location(s) and describe what it was like growing up there:

ANSWER HERE

What was your family life like? Did you spend much time with your parents? Do you have any siblings? If so, what are your relationships like?:

ANSWER HERE

What was school like? Did you have any problems? Did you enjoy school? What were your grades like?:

ANSWER HERE

Did you engage in any extracurricular activities, such as academic, artistic, or sporting clubs?:

ANSWER HERE

Have you ever been convicted of a crime or misdemeanour? If yes, please explain, list conviction, and list any sentences associated with convictions:

ANSWER HERE

Do/did you abuse controlled substances, including but not limited to tobacco, alcohol, street drugs and/or prescription medications?:

ANSWER HERE


Lastly, please tell us about yourself. How do you feel about yourself and what you have done with your life? If you have committed crimes, how do you feel about those now? What are your hopes for the future?:

ANSWER HERE


________________________________________________________________________

◦ OUT OF CHARACTER SECTION ◦

What are they not telling us? What secrets do they have to hide? What back story are we not hearing? This is where you can tell us all the things your character wouldn't put on an application, or others don't know:

ANSWER HERE

Your Nickname: ANSWER HERE
Your Chat Box Screen Name: ANSWER HERE
Your Character's Playby: ANSWER HERE


Code:
[center]

[font=Garamond][size=22][color=#664129] ◦ FIRSTNAME LASTNAME ◦ [/color][/size][/font]

Small Image of your Character Play-By Here, in IMG tags.

________________________________________________________________________[/center]

[table border="0"][tr][td] [img]http://img189.imageshack.us/img189/6942/applogo.jpg[/img] [/td][td]
[color=#664129][b] D.O.B:[/b][/color] dd/mm/yyyy
[color=#664129][b] AGE:[/b][/color] 14-17
[color=#664129][b] GENDER:[/b][/color] M/F
[color=#664129][b] STREET ADDRESS:[/b][/color] House Number & Street
[color=#664129][b] TOWN/CITY:[/b][/color] Town or City
[color=#664129][b] STATE:[/b][/color] County, or US State
[color=#664129][b] HEIGHT:[/b][/color] In feet & Inches
[color=#664129][b] WEIGHT:[/b][/color] In Pounds
[color=#664129][b] ETHNICITY:[/b][/color] Caucasian/Hispanic/Asian, etc
[color=#664129][b] DISTINGUISHING MARKS:[/b][/color] Any other distinguishing marks such as birth marks, moles, piercings and tattoos.

[/td][/tr][/table]

[center]________________________________________________________________________

[font=Garamond][size=18][color=#664129] ◦ MEDICAL HISTORY ◦ [/color][/size][/font][/center]

[color=#664129][b]Do you have any ongoing medical issues for which you require treatment or medication?:[/b][/color]

ANSWER HERE

[color=#664129][b]Are you aware of any allergies? If so, please list allergy, age of onset and any medications or treatments you require or recieve:[/b][/color]

ANSWER HERE

[color=#664129][b]Have you had any surgeries or invasive procedures in the past? If yes, please list reason and approximate age of procedure:[/b][/color]

ANSWER HERE

[color=#664129][b]Do you take any medications or supplements daily? Do you follow any treatment plans? Please list medications or treatments, and reasons below:[/b][/color]

ANSWER HERE

[color=#664129][b]Do you use tobacco, consume alcohol, or use any other drugs including street drugs and/or prescription medications not prescribed to you? If yes, please list number of packs a day, number of drinks a day, and/or drugs consumed below:[/b][/color]

ANSWER HERE


[center]________________________________________________________________________

[font=Garamond][size=18][color=#664129] ◦ PSYCHIATRIC SCREENING ◦ [/color][/size][/font][/center]

[color=#664129][b]Please describe, to the best of your ability, your emotional and mental state of wellbeing:[/b][/color]

ANSWER HERE

[color=#664129][b]Have you been diagnosed with any psychiatric or psychological ailments? Please list any diagnoses below, and any treatments or medications prescribed to you. Please include name of medications, dosage, and number of doses per day:[/b][/color]

ANSWER HERE

[color=#664129][b]Have you ever been hospitalised or referred to regular outpatient care due to these ailments or associated incidents? If so, please note where, and at roughly what age:[/b][/color]

ANSWER HERE

[color=#664129][b]How have these ailments affected you and your life? Are there any major life instances you feel have been directly affected by these ailments, such as suicide attempts, criminal activities, etc?:[/b][/color]

ANSWER HERE

[color=#664129][b]What is your social life like? Do you have many friends or relationships? How are your family relationships?:[/b][/color]

ANSWER HERE

[color=#664129][b]Do you believe your life circumstances have contributed to any ailments? If so, what circumstances, and why do you feel they have contributed?:[/b][/color]

ANSWER HERE

[color=#664129][b]If you could change one past event that has happened to you, what would it be, and why?:[/b][/color]

ANSWER HERE

[color=#664129][b]Do you wish to rehabilitate from your ailment(s)? If so, how do you feel this would best be accomplished?:[/b][/color]

ANSWER HERE

[center]________________________________________________________________________

[font=Garamond][size=18][color=#664129] ◦ ENVIRONMENTAL HISTORY ◦ [/color][/size][/font][/center]

[color=#664129][b]Where did you grow up? Please list the location(s) and describe what it was like growing up there:[/b][/color]

ANSWER HERE

[color=#664129][b]What was your family life like? Did you spend much time with your parents? Do you have any siblings? If so, what are your relationships like?:[/b][/color]

ANSWER HERE

[color=#664129][b]What was school like? Did you have any problems? Did you enjoy school? What were your grades like?:[/b][/color]

ANSWER HERE

[color=#664129][b]Did you engage in any extracurricular activities, such as academic, artistic, or sporting clubs?:[/b][/color]

ANSWER HERE

[color=#664129][b]Have you ever been convicted of a crime or misdemeanour? If yes, please explain, list conviction, and list any sentences associated with convictions:[/b][/color]

ANSWER HERE

[color=#664129][b]Do/did you abuse controlled substances, including but not limited to tobacco, alcohol, street drugs and/or prescription medications?:[/b][/color]

ANSWER HERE


[color=#664129][b]Lastly, please tell us about yourself. How do you feel about yourself and what you have done with your life? If you have committed crimes, how do you feel about those now? What are your hopes for the future?:[/b][/color]

ANSWER HERE


[center]________________________________________________________________________

[font=Garamond][size=18][color=#664129] ◦ OUT OF CHARACTER SECTION ◦ [/color][/size][/font][/center]

[color=#664129][b]What are they not telling us? What secrets do they have to hide? What back story are we not hearing? This is where you can tell us all the things your character wouldn't put on an application, or others don't know:[/b][/color]

ANSWER HERE

[color=#664129][b]Your Nickname:[/b][/color] ANSWER HERE
[color=#664129][b]Your Chat Box Screen Name:[/b][/color] ANSWER HERE
[color=#664129][b]Your Character's Playby:[/b][/color] ANSWER HERE
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