Mariah Rose

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: ROSE, MARIAH

Age: 14
DOB: 07/17/1996
Gender: Female
Address: 2723 Crew Crook Cruickshank Rd.
City: Phoenicia
State: New York
Ethnicity: Caucasian
Height: 5'3"
Weight: Well, I was 120 pounds when I got to Hadley, but I know I've lost weight, so 110? 115?
Eye Color: Brown
Hair Color: Brown
Distinguishing Marks: I have a mole on the left side of my face above my upper lip and a small birthmark on my right elbow, but other than that, nothing.


Medical History:

Please list any and all allergies and age of onset below:
Peanuts, age 5 - I was eating a PB&J and I broke out in hives.
Strawberries, age 5 - same as above, but we didn't confirm it until I had a piece of strawberry shortcake a few months later.
Latex, age 7 - we were blowing up balloons for a school party and my lips got all swollen.

Are you aware of any ongoing medical issues?:
No, I don't think I have any.

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:
No.



Psychiatric History:

Have you been diagnosed with any psychiatric issues? If so, please list diagnoses and age of diagnoses below:
Yes. I was diagnosed with depression at age 13.

If you answered yes to the above, please list any and all prescriptions, including dosage and frequency of dosage, and other treatment plans below:
I took Zoloft, 50mg, once a day, for a month after my initial diagnosis, but it caused my blood pressure to skyrocket. My doctor, Lucinda Blaine, switched me to Prozac, 20mg, once a day, and I took that until I arrived at Hadley Institute in July of 2010, at which point I switched to...another pill, once a day. I don't know exactly what it was.

If you answered yes to the above, please describe noted feelings, symptoms, triggers and incidents associated with the diagnoses, and ages of incidents below:
Oh, gosh. I don't really know how to answer this. I guess the initial trigger for my depression was a series of rapes by my older brother, Robert Rose, now nineteen and currently in jail (as far as I know). Every time he raped me, I would get scared and feel kind of dirty. The first time, which was July 17, 2008 (my twelfth birthday), I tried to drown myself the next day and probably would have if Daddy hadn't saved me. The second time, Christmas Eve 2009 (when I was thirteen), I ate four peanut butter cookies that had been left out for "Santa" and my throat started swelling up. The third time was Robert's eighteenth birthday, March 15, 2010 (thirteen again), and I tried to swallow a whole bottle of aspirin. Since I've been at Hadley, I've also occasionally had issues because of what my father did to me. Usually when I have those problems, I start crying, or huddle in a corner of my bed and ignore everybody, trying to feel safe again.

Have you ever been hospitalised for these diagnoses? If yes, please provide facility name(s) and age of admissions and discharges:
Yes. At the age of 13 - March of 2010, after the police arrested Daddy and Robert - I was placed in the Shofair Children's Hospital in Helena, Montana, under the care of Dr. Lucinda Blaine. I was discharged in July of 2010, age 14, and sent to the Hadley Institute for Troubled Teens, where I attended until now, under the care of Dr. Bamidele Wynn.

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:
I think my mother's mother had depression, but as she died when I was three I don't know if that was an official diagnosis or just a retroactive guess.



Environmental History:

Are you aware of any complications during your birth? If yes, please explain below:
I was a breech baby, but other than 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:
No, I did everything right on schedule.

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:
Okay, well, I grew up in Hobson, Montana, on a ranch. I spent most of my free time helping out on the ranch, learning to be a "good rancher's wife," although we didn't live off the ranch. Daddy was a stationmaster and Mama was a bartender. The biggest part of my childhood was spent with Daddy. I liked it a lot, up until I was about twelve and Rob started hurting me, but looking back on it now, I don't like it at all. It wasn't a good place for a kid. It's the reason I'm here today.

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 got mostly A's and B's. School was a lot of fun. Still is, actually, it's one of my favorite parts of Hadley.

Do/did you have many friends growing up? Do/did you have a best friend? If yes, please explain below:
I had my running gang, and my best friend in middle school was Dana something (I forget what her last name was), but I didn't really have any good friends until the last year when I've been at Hadley. Nell Hedon and Roscoe Jones were probably the two people I trusted the most.

Do/did you pursue any extra curricular activities or talents? If yes, please explain below:
I was in the Drama Club and the Art Club. Mostly I just hung out on the ranch, though.

If sexually active, please list age of onset and sexual preference below. If not sexually active, are you aware of a sexual preference?:
I guess I technically became sexually active at the age of five when my daddy started taking care of raping me. I've never had sex with anyone out of my choice, though, but if I did I think I'm bisexual.



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, I haven't.

Have you ever been convicted of a crime? If yes, please list conviction, age of conviction and circumstances below:
No.

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:
Unless attempting suicide counts, then no.



Personal Interview:

Describe yourself to the best of your ability in only five words:
Mousy, quiet, shy, bibliophile, nervous

Is the glass half empty, or half full? Explain your answer below:
Half-full. It's always better to look on the bright side of everything.

If you could change only one thing in your life, what would it be, and why?:
I would have told somebody what Daddy was doing to me before Robert had a chance to start. Even if I thought it was all innocent, I still should have said something to somebody, and maybe I wouldn't be so messed up and Robert wouldn't have hurt me.

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 don't know. I used to feel bad about telling the police about Robert because I didn't want Daddy to go to jail, but I don't know how I feel anymore. Maybe everything happened the way it was supposed to. After all, if everything hadn't happened the way it did, I would never have met Nell or Roscoe or Dr. Wynn.

What are your goals in life, and how do you feel those would be best accomplished?:
I don't really have any goals yet. I don't know what I want to do with my life. Anyway, who knows if I'll ever even make it to be old enough to do anything worthwhile?

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 guess mostly because that's where a lot of the other Hadley kids are going. It's not like I have anywhere else to go. Whatever I end up doing with my life, I think it will help me get there if I can still be around at least some people that I know.



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:

Simon Powell 16/05/2011

Welcome to St. Christina's Psychiatric Rehabilitation Center. Your ward and room assignments can be found below, along with the name of your primary therapist. Please familiarise yourself with all patient handbooks and codes of conduct.

Building: Bennett Home for Girls
Ward: C
Room: C1
Bed: 1
Primary Therapist: Dr. __________

OOC Information: All information below this line is not known by the patient, but is available on the patient's file, viewable only by staff.

Study Group(s):

Primary:Depression/Suicide Risk

Final Application Approval Steps for Players:


Before you can begin play on STC, you must complete these final steps:

• Sign up your playby on the faceclaim.
  
• Sign up for the who plays who list.
  
• Sign up for your assigned membergroup (shown above) HERE (Pay close attention to pick the correct usergroup listed on this approval stamp! Characters that are not signed up for their correct membergroups after approval will be subject to deletion during the next activity check.)
  
• Familiarise Yourself with you Patient Hanbook, located in St. Christina's Rosters and Information forum, on the main board.

Code:

[center][font=garamond][size=22][color=#555555][b] -File Note- [/b][/color][/size][/font]

    _____________________________________________________________[/center]

    [b]Patient Name:[/b] Rose, Mariah
    [b]Primary Study Group:[/b] Depression/Suicide Risk
    [b]Primary Therapist:[/b] Dr. ___________
    [b]Building:[/b] Bennett
    [b]Ward:[/b] C

    [center]_____________________________________________________________[/center]

    [b]Note Subject:[/b] (Therapy Report, Medication Change, Dormitory Reassignment, Medical Report, Behavioural Report, Progress Report, Procedure Report, Disciplinary Report, etc.)

    [b]Note Contents:[/b] (Explain behaviour observations, patient actions, procedures, medication changes, disciplinary actions, medical reports, etc. here)

    [b]Note Author:[/b] (Your character name here.)

    [b]Other:[/b] (Optional extra notes here.)