LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last)
Jacklyn Nicole Moretti

Avatar Name (if different than above)
Rosera Paine

Age:
15 (Will be turning 16 on the 19th)

Grade & School:
10th grade, Homeschooled

Race/Ethnic Background:
Hispanic/African American

Please list name and relationship of child's guardian(s).:
Adopted Mother: Josephina Moretti. ((Kieran McCollum

Please note the infraction which resulted in the child's current detention:

Assult with a skateboard.
Disturbing the peace
Severe anger issues

Please detail below the child's criminal history.

Suspected aid in the kidnapping of a child
Assault with a skateboard.
Disturbing the peace
Assault with a deadly weapon
Theft
Resisting arrest

Please detail any previous psychiatric/counseling sessions the child may have been involved with prior to arrival at LLJC.
None.

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

Third degree grease burns. ((Right arm, to the middle of her forearm))
Stabbed in the arm and stomach.

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

Celexa- Anti depressant
Protein powder for her food