LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last)
-Tanner Jacob Halsey

Avatar Name (if different than above)
-Tanner Raleigh

Age:
-15

Grade & School:
-Unknown - no schooling (note to counselors to forward infornation to Social worker)

Race/Ethnic Background:
-Italian

Please list name and relationship of child's guardian(s).:
-Legal guardians: Jace Hasley and Jake kuhn

Birth Mother - Harvest Dezno

Please note the infraction which resulted in the child's current detention:
-assualt on another minor

Please detail below the child's criminal history.
-Robbery

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.)
no serious physical trauma
Self-diagnosis of bipolar disorder ('moody' like his father. look into history)

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

N/A

Child has been assigned to: Melia Cerise