MARGOT'S OFFICES
Apr 24, 2014 16:59:36 GMT -8
Post by Thy Dungyeon Maestyr on Apr 24, 2014 16:59:36 GMT -8
<<bearbeite!!>> Add Eli to this thread
Chauffeurs Eli and Vitus drove everyone to an unevenly paved pay lot in the slightly less skeevy end of south downtown. Vitus led them to a low rent twenty story office building, secured welcome for everyone via the intercom, thru a dimly lit lobby to a brightly lit but slow elevator to another dark lobby on the 7th floor to a comfortably lit office. He held the glass door open while everyone went in single file. The receptionist was quick to greet them.
Receptionist-
"I'm Tina. Let me know if you need anything while you wait, OK? Now," she opened a manila envelope, removed the contents, and laid it on the table before passing each person a few sheets of paper stapled together, "Fill these out as much as you feel comfortable, do not share the information from them with anyone else, and return them to the envelope when you are done. We don't ask for any identifying information, but we insist that you use the same name every time you come here unless you need to make a special arrangement otherwise. Use a pseudonym if you like, just be consistent about it. "
Vitus-
"You're new."
Receptionist-
"I've been here for six years."
Vitus-
"Oh."
There were pens & a few clipboards on the table & the paperwork read as follows -
Name: _________________________
Gender: ___________ Ethnicity:_____________ Sexual Orientation:__________
Are you sexually active? ______________________ Marital Status:___________
Do you have children?___________ What are your religious beliefs?___________
What are your family’s religious beliefs?_________________________________
What is you occupation?_____________________________________________
Do you require language assistance with Glennish?________________________
Any general information about family members or your relationships with others
that may be relevant to mental or physical health issues? ___________________
Does anyone in your immediate or extended family have a history of mental health
or substance/alcohol abuse issues?____________________________________
Substance Use History
Do you drink alcohol? YES/NO # drinks/week:___________________________
If yes: Have you ever felt you should cut down on your drinking? YES/NO
Have people annoyed you by criticizing your drinking? YES/NO
Have you ever felt bad or guilty about your drinking? YES/NO
Have you ever had a drink in the morning to steady your nerves or get rid
of hangover symptoms (eye-opener?) YES/NO
Do you smoke cigarettes or use other tobacco products? YES/NO # per day___
Please check the following drugs that you have used in the past or currently use:
Cannabis__ Barbiturates__ Benzodiazepines (Vaylor, Amavar, Prosec)__
LSD (acid)__ Mescaline__ PCP__ Mushrooms__ Caffeine__
Amphetamines (Attentor, Focalvine, Paramol, etc.)__ Ecstasy__ Cocaine__
Guarana__ Khat__ Pseuodoephedrine__ DXM__ Codeine__
Heroin__ Hydrocodone__ Oxycodone__ Morphine__ Opium__
Inhalants__ Others________________________________________
Any other drugs, herbs, vitamins or supplements: _________________________
Describe the frequency of use and the reason for use of the above drugs: ________
________________________________________________________________
How many hours do you sleep during a 24 hour period?_____________________
Do you have any trouble falling asleep?_________________________________
Do you have any trouble staying asleep?________________________________
What are your normal bed and wake times? ______________________________
What do you do for fun?_____________________________________________
Have you ever been in therapy, substance abuse counseling, or taken psychiatric
medication in the past? If so, please give details of medications tried, responses and
side effects, and reasons for counseling. _________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Have you ever been hospitalized for mental health or substance abuse issues? If yes,
Why and for how long were you inpatient? _______________________________
________________________________________________________________
________________________________________________________________
Any past or present suicidal thoughts, plans or attempts? YES/NO
Explain__________________________________________________________
________________________________________________________________
Any past or present thoughts about harming someone else? YES/NO
Explain__________________________________________________________
Did any of the following events occur during your childhood or adolescence?
(Check all descriptions that apply)
Physical Abuse__ Verbal Abuse__ Witness to violence__
Teasing/Bullying__ Sexual abuse or rape__ Medical Problems__
Rigid religious way of life__ Trauma (fire, crime victim, natural disaster)__
Drug/alcohol abuse__ Extreme Parental Control/Pressure__
In the past and/or currently, have you ever experienced and problems with any of
the following symptoms or behaviors: (Check all that apply)
Self-harm (cutting, burning, overdosing)__ suicidal thoughts, plans or attempts__
Using illegal or prescription drugs__ Excessive use of alcohol__ blackouts__
Memory disturbances__ Self-induced vomiting__ Laxative Abuse__
Odd or irrational behavior__ Depression__ Nervous Tics__
Impulsiveness__ obsessions/compulsions/rituals__ restrictive eating__
Aggressive or violent behavior__ legal problems__ anxious avoidance__
Seriously risky behavior__ Promiscuity__ appetite/weight loss__
Inability to sleep for more than 48 hours straight__ Insomnia/sleep disturbance__
Loss of interest in sex (if sexual)__ Concerns about sexual identity__
Hallucinations (hearing voices, seeing or hearing things others do not see)__
Any additional symptoms of concern?:___________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
The following buster-ass tricks were in attendance,
Joined shortly by
.
((This would be a good place to post Polyvore outfits, and maybe say in "spoilered" text how your guy filled out the form, to whatever extent you feel like doing so.))
{originally}
The following buster-ass tricks were in attendance,
Joined shortly by
.
((This would be a good place to post Polyvore outfits, and maybe say in "spoilered" text how your guy filled out the form, to whatever extent you feel like doing so.))
The following buster-ass tricks were in attendance,
Joined shortly by
.
((This would be a good place to post Polyvore outfits, and maybe say in "spoilered" text how your guy filled out the form, to whatever extent you feel like doing so.))