Taken by Raynee Jewell

LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last)
Piper Tallulah Rewell-Wells

Avatar Name (if different than above)
Piper Rewell

Age:
17

Grade & School:
sophomore, homeschooled

Race/Ethnic Background:
pure southern white

Please list name and relationship of child's guardian(s).:

Sadie Wells (Sadesh Helendale) mother
Tah Wells (Tah Crazyboi) father

Please note the infraction which resulted in the child's current detention:
1)arrested for smashing up the Clam
2)resisting arrest, obstruction

Please detail below the child's criminal history.
Stint in Alabama juvenile facility for arson and arson with malicious intent; in Hathian 6 mo ago for arson and vandalism. History of petty theft, arson.

Please detail any previous psychiatric/counseling sessions the child may have been involved with prior to arrival at LLJC.
Counseled last time at LLJC, plus a week of private therapy after a brain injury, and counselling for drug/alcohol treatment, ongoing. As well as anger issues therapy

Please detail medical history (physical or psychological) of which the LLJC staff should be aware. (ie. diabeties, schizophrenia, Tourette's Syndrome, etc.)
Slight anxiety-induced asthma, never been diagnosed. Currently a stab wound to the upper abdoment but was stitched up badly, and asepticlly. May require some medical attention soon. (not yet been disclosed ICly)

Please detail any medications and the corresponding doses the child has been prescribed.
None