LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM
As taken by Melia Cerise.
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.
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.
None