LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last)
-Ivy Kyoshiku Watson

Avatar Name (if different than above)
-Adrienne Adored

Age:
-15

Grade & School:
-Upcoming freshman in Hathian High

Race/Ethnic Background:
-Caucasian

Please list name and relationship of child's guardian(s).:
-Legal guardians: Billie Watson and Jingy Watson
-Birth parents: same as above

Please note the infraction which resulted in the child's current detention:
-Vandalism and evasion of arrest

Please detail below the child's criminal history.
-No prior criminal record

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

Please detail medical history (physical or psychological) of which the LLJC staff should be aware. (ie. diabeties, schizophrenia, Tourette's Syndrome, etc.)
Allergic to lemons

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

N/A

Child has been assigned: Sadie Helendale