LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last)
Gage Ever Margetts

Avatar Name (if different than above)
Chance Greene

Age:
15

Grade & School:
Msgr. Scanlan Private High School - Grade 10

Race/Ethnic Background:
Spanish/Puerto Rican/Japanese/Caucasian

Please list name and relationship of child's guardian(s).:
Epic Maidstone - Mother

Please note the infraction which resulted in the child's current detention:
HPC 504 Possession of a Prohibited Item [Box Cutter]
HPC 705 Public Drunkenness

Please detail below the child's criminal history.
1 count resisting arrest
1 count possesion with intent

Please detail any previous psychiatric/counseling sessions the child may have been involved with prior to arrival at LLJC.

Please detail medical history (physical or psychological) of which the LLJC staff should be aware. (ie. diabeties, schizophrenia, Tourette's Syndrome, etc.)
Wears eyeglasses. Asthmatic. Mild OCD as a young child.

Please detail any medications and the corresponding doses the child has been prescribed.
Albuterol pump

Child has been assigned __________________________(name of counselor)