LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last)
- Ryan 'Ryan' Skytower

Avatar Name (if different than above)
- rabid bedlam
AKA Teddybear

Age:
-15

Grade & School:
-11th in Hathian High

Race/Ethnic Background:
-Indian from the Acolapissa tribe

Please list name and relationship of child's guardian(s).:
-Legal guardians: Lexii Walcott, Pook skytower, and Lars Calhern

Please note the infraction which resulted in the child's current detention:
-assault, resisting arrest, assault on a police officer and possesion of a controlled substance over the personal limit

Please detail below the child's criminal history.
-Assualts, larceny, arson (pull criminal record for more info)

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

Please detail medical history (physical or psychological) of which the LLJC staff should be aware. (ie. diabeties, schizophrenia, Tourette's Syndrome, etc.)
history of ashtma, pnemonia, and bronchitis.
diagnosed as ODD, ADHD,
labeled with conduct disorder and more from last juvie session (note to counselors: look this up)
born addicted to heroine.

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

treatment for swine flu

Child has been assigned to: Jacinda Harper