LOWER LOUISIANA JUVENILE CENTER
PRELIMINARY PATIENT QUESTIONNAIRE/INTAKE FORM

Please answer all questions and complete all fields

Character Name (First, Middle, Last) Yukio Seoung

Avatar Name (if different than above)

Age: 16

Grade & School: unknown

Race/Ethnic Background: Japanese

Please list name and relationship of child's guardian(s).: None..

Please note the infraction which resulted in the child's current detention:
Public intoxication and assault on an officer.

Please detail below the child's criminal history.

Public intoxication and assault on an officer.

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.)
None other than treatment for taser wounds and random broken bones from playing baseball when he was a kid.

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

Child has been assigned __________________________(name of counselor)