Levi Dubois

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: DUBOIS, LEVI

Age: 16
DOB: 11/11/1994
Gender: Male
Address: Hadley Institute, 2723 Cruickshank Rd
City: Phoenicia
State: New York
Ethnicity: Caucasian
Height: 6’
Weight: 127 lbs
Eye Color: Brown
Hair Color: Brunette
Distinguishing Marks: Several scars on his arms, legs and neck.

Medical History:

Please list any and all allergies and age of onset below:
No known allergies.

Are you aware of any ongoing medical issues?:
None

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:
Not currently. I used to do methamphetamine, marijunana, smoked and drank but it wasn’t like I kept track.



Psychiatric History:

Have you been diagnosed with any psychiatric issues? If so, please list diagnoses and age of diagnoses below:
I was diagnosed with Reactive Attachment Disorder with self-injury at age eleven. Methamphetamine addiction at age fourteen and have been told I show signs of masochism at age fifteen.

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’ve used to be on Fluoxetine. I was taken off of that after my stay in rehab. Then I came to Hadley and was put on something though I don’t know what it is.


If you answered yes to the above, please describe noted feelings, symptoms, triggers and incidents associated with the diagnoses, and ages of incidents below:
I like to injure myself. I’ve cut myself with a knife, drank poisonous substances, placed my hand though a window, punched a mirror and driven a car into a tree. I enjoy provoking fights just to get hit, punched or harmed in general by another person. I only feel something when I’m in some sort of physical pain.

Have you ever been hospitalised for these diagnoses? If yes, please provide facility name(s) and age of admissions and discharges:
At age eleven I was put in my first psychiatric hospital. Age thirteen I was moved to hospital number two. Age Fourteen I was moved to hospital number three. Age Fifteen came number four. Age Sixteen I was sent to Hadley.

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 biological parents left me in a dumpster so I have no idea. My adoptive family I’ve got one sister that is anorexic. It doesn’t affect me; I don’t really care that she won’t eat.



Environmental History:

Are you aware of any complications during your birth? If yes, please explain below:
I don’t know.

Are you aware of any difficulties in development during your infancy, such as learning disabilities, speech impediments, etc? If yes, please explain below:
I have been told there weren’t any problems like that.

Are you aware of any long term separation from your mother during your infancy? If yes, please explain below:
I was left in a dumpster when I was about two weeks old. Apparently, I had been left there for around 24 hours. I was adopted about a month later.

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 in East Hampton, New York. I lived on an estate with several acres of land with my six adopted siblings. Nothing traumatic happened except what I did to myself. It didn’t affect I was always watching everyone like an outsider and never really wanted any connections with people.

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 never really cared about school. I would get into fights; I brought a knife to school and drank a small amount cleaning solution. I had to repeat the sixth and eight grades and I never cared enough to get good grades.

Do/did you have many friends growing up? Do/did you have a best friend? If yes, please explain below:
I never made friends. I never wanted any.

Do/did you pursue any extra curricular activities or talents? If yes, please explain below:
I don’t care about that, so no.

If sexually active, please list age of onset and sexual preference below. If not sexually active, are you aware of a sexual preference?:
I prefer girls and I think I was twelve or thirteen.



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 was sent to rehab for methamphetamine addiction. I used other things marijuana and alcohol but don’t think I abused them.

Have you ever been convicted of a crime? If yes, please list conviction, age of conviction and circumstances below:
Yes. I was convicted of driving without a license at fourteen.
Possession of narcotics at fourteen and fifteen.

If you answered yes to the above, please list sentences connected to these convictions below:
Yes. I was convicted of driving without a license. Was made to do some stupid community service in a soup kitchen and I can’t get my license until I’m eighteen. I also was convicted of possession of narcotics twice and sent to rehab both times.

Have you ever knowingly committed a crime for which you were not convicted or sentenced? If yes, please explain below:
Yes. I’ve done illegal drugs at times when I haven’t been caught. I’ve caused property damage, drank alcohol and brought a knife on to school property.


Personal Interview:

Describe yourself to the best of your ability in only five words:
numb, watching, recluse, uncaring, harmful

Is the glass half empty, or half full? Explain your answer below:
Half empty. I don’t care which one it is really nor do I care why I think that.

If you could change only one thing in your life, what would it be, and why?:
Not sure I would change anything.

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?:
It hasn’t except I can’t just live my life now. I injure myself to feel something and I get into trouble for that.

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

To get out of any kind of institution for good.

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?:

It was chosen for me. Though I think there was a thought from the people that put me here that I’m a danger to myself or something. And I’ve been told they would like me to become a productive member of society one day.



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:

Levi Dubois 05/18/2011

This application is currently pending. Below, you'll find the reasons for this pending notice. If you wish to continue the application process, please follow the points laid out below by a member of STC's staff.

• Two itty bitty things. Number 1, you missed a question in the legal history section. "Have you ever been convicted of a crime? If yes, please list conviction, age of conviction and circumstances below." Fill it in please.
  
  
• Since Levi filled the form in willingly and all on his own he should be the one to sign in. Please change that up and he'll be good to go.
  

Please reply to this thread once you have edited your application, to let us know, and a member of STC's staff will review your application again at our next possible convenience..

Edited.

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: Robertson
Wing: -
Ward: A
Room: A1
Bed: 2
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
Antisocial Behaviors
Drug Abuse

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] Dubois, Levi
[b]Primary Study Group:[/b] Depression/Suicide Risk
[b]Primary Therapist:[/b] Dr. ___________
[b]Building:[/b] Robertson
[b]Wing:[/b] -
[b]Ward:[/b] A

[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.)