Patient Application Template

**Admin Ghost** Fri Aug 27, 2010 6:13 pm

. Before You Fill Out an Application .

Here's some things you need to read:

Colours and fonts: Please do not change your colours and fonts from the standard. This is to maintain uniformity in the filing cabinet, and to save the eyes of the staff who have to read the applications. Likewise, do not edit the application code in any way except where indicated.
Application Image: Please ensure that your application image is no larger that 400px by 400px.
The Questions: Please answer all questions in full, and try to be consistent with your answers and your timeline. This is a written interview, so you should fill it out as if you're filling out an admissions chart.
Application Method: The application must be filled out by either the patient or a psychologist/psychiatrist/counsellor. This means it cannot be filled out by family members or friends, etc. Only ONE person may fill it out (this means only one voice on the application.) If you wish to add a short note from a psychiatrist, you may add on a short letter or the like at the very end of the application.
Where & How to Post: Highlight the code forthe application, and post it, with your answers filled in, in a new thread in the APPLICATION PROCESS board. The thread must be titled: Patient: Firstname Lastname.

. The Application .
___________________________________________________

Patient Application Template 2ymj6ok

__________________________________________

-Lastname Firstname-

OPTIONAL IMAGE HERE

Date of Birth:

Age:

Gender:

Address:

Physical Appearance:

-Medical History-

Do you suffer from any ongoing medical conditions such as heart conditions, diabetes, asthma or other long-term physical disabilities, diseases or afflictions?

ANSWER HERE

Do you have any allergies to foods, inhalants or medications? Please list allergies and age of onset below.

ANSWER HERE

Does your family have a history of any ongoing medical conditions such as heart conditions, diabetes, asthma or other long-term physical disabilities, diseases or afflictions?

ANSWER HERE

-Psychological History-

Do you, or have you ever suffered from a mental affliction, or do you feel that you have problems with your state of mind? Examples could be anxiety, depression, seeing or hearing things that are not there, suffering from uncontrollable impulses, or entertaining damaging thoughts such as wanting to harm/kill oneself or do something damaging to another person. Have you ever abused controlled substances, alcohol, or prescription medications?

ANSWER HERE

Have you ever seen someone for these problems or addictions? Or have you been hospitalised or housed in an institution or home for people who suffer from mental afflictions, or admitted to a drug rehabilitation centre? If so, for how long, and what was your diagnosis?

ANSWER HERE

-Personal History-

Where were you born, and where did you grow up? Were there any complications during your birth? What was your infancy like?

ANSWER HERE

Did you ever have any long-term separation from your parents?

ANSWER HERE

Do you have any siblings? If so, did you get along well with them?

ANSWER HERE

Did you attend public or private school, and if so, what were your grades like and how did you feel about it?

ANSWER HERE

Do you have an interest in the opposite or same sex, and if so, when did you become aware of this interest?

ANSWER HERE

Were you ever admitted to a psychiatric or correctional facility for juveniles, and if so why were you admitted, and how did you feel about it?

ANSWER HERE

-Criminal History-

Have you ever been convicted of a crime? If so, what was the conviction, and was was the sentence served, or fine paid?

ANSWER HERE

Have you ever taken or abused controlled substances? Have you ever had an addiction to prescription medications, or have you abused alcohol?

ANSWER HERE

-Personal Interview-

What are your goals in life?

ANSWER HERE

How do you hope that our facilities might help you in achieving those goals?

ANSWER HERE

Finally, tell us a bit about yourself.

ANSWER HERE

-Legal Documentation-

By agreeing to admission to our facilities, you hereby agree to abide by all rules and terms of service outlined in patient or resident handbooks, rules and codes of conduct. You hereby agree to waive your right to voluntary dismissal from our facilities until such a time as facility heads of staff sign paperwork for your release. You hereby agree to comply with facility staff recommendations, demands, or outlines for treatment. You hereby waive your right to informed medical consent before medication changes or medical procedures. You hereby agree to waive your right to hold Crane Pharmaceuticals and its Subsidiaries responsible for any personal harm or distress incurred during treatment. Crane Pharmaceuticals and its Subsidiaries reserve the right to add or amend these terms of service at any time.

Please sign and date below.

Firstname Lastname

Crane Pharmaceuticals ®2009, 2010

Code:: [center][IMG]http://i33.tinypic.com/2ymj6ok.png[/IMG] __________________________________________ [size=24][font=garamond][b] -Lastname Firstname-[/b][/font][/size] OPTIONAL IMAGE HERE[/center] [list][b]Date of Birth:[/b] [b]Age:[/b] [b]Gender:[/b] [b]Address:[/b] (Within the US) [b]Physical Appearance:[/b] [/list] [center][size=20][font=garamond][b] -Medical History-[/b][/font][/size][/center] [size=18][font=garamond][b] Do you suffer from any ongoing medical conditions such as heart conditions, diabetes, asthma or other long-term physical disabilities, diseases or afflictions?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b] Do you have any allergies to foods, inhalants or medications? Please list allergies and age of onset below.[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b] Does your family have a history of any ongoing medical conditions such as heart conditions, diabetes, asthma or other long-term physical disabilities, diseases or afflictions?[/b][/font][/size] ANSWER HERE [center][size=20][font=garamond][b] -Psychological History-[/b][/font][/size][/center] [size=18][font=garamond][b]Do you, or have you ever suffered from a mental affliction, or do you feel that you have problems with your state of mind? Examples could be anxiety, depression, seeing or hearing things that are not there, suffering from uncontrollable impulses, or entertaining damaging thoughts such as wanting to harm/kill oneself or do something damaging to another person. Have you ever abused controlled substances, alcohol, or prescription medications?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Have you ever seen someone for these problems or addictions? Or have you been hospitalised or housed in an institution or home for people who suffer from mental afflictions, or admitted to a drug rehabilitation centre? If so, for how long, and what was your diagnosis?[/b][/font][/size] ANSWER HERE [center][size=20][font=garamond][b] -Personal History-[/b][/font][/size][/center] [size=18][font=garamond][b]Where were you born, and where did you grow up? Were there any complications during your birth? What was your infancy like?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Did you ever have any long-term separation from your parents?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Do you have any siblings? If so, did you get along well with them?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Did you attend public or private school, and if so, what were your grades like and how did you feel about it?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Do you have an interest in the opposite or same sex, and if so, when did you become aware of this interest?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Were you ever admitted to a psychiatric or correctional facility for juveniles, and if so why were you admitted, and how did you feel about it? [/b][/font][/size] ANSWER HERE [center][size=20][font=garamond][b] -Criminal History-[/b][/font][/size][/center] [size=18][font=garamond][b]Have you ever been convicted of a crime? If so, what was the conviction, and was was the sentence served, or fine paid? [/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Have you ever taken or abused controlled substances? Have you ever had an addiction to prescription medications, or have you abused alcohol? [/b][/font][/size] ANSWER HERE [center][size=20][font=garamond][b] -Personal Interview-[/b][/font][/size][/center] [size=18][font=garamond][b]What are your goals in life?[/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]How do you hope that our facilities might help you in achieving those goals? [/b][/font][/size] ANSWER HERE [size=18][font=garamond][b]Finally, tell us a bit about yourself.[/b][/font][/size] ANSWER HERE [center][size=20][font=garamond][b] -Legal Documentation-[/b][/font][/size][/center] [list][size=9]By agreeing to admission to our facilities, you hereby agree to abide by all rules and terms of service outlined in patient or resident handbooks, rules and codes of conduct. You hereby agree to waive your right to voluntary dismissal from our facilities until such a time as facility heads of staff sign paperwork for your release. You hereby agree to comply with facility staff recommendations, demands, or outlines for treatment. You hereby waive your right to informed medical consent before medication changes or medical procedures. You hereby agree to waive your right to hold Crane Pharmaceuticals and its Subsidiaries responsible for any personal harm or distress incurred during treatment. Crane Pharmaceuticals and its Subsidiaries reserve the right to add or amend these terms of service at any time. [/size][/list] [size=18][font=garamond][b]Please sign and date below.[/b][/font][/size] [list][font=garamond][size=26][i] Firstname Lastname[/i][/size][/font] mm/mm/yyyy [/list] [right][size=8] Crane Pharmaceuticals ®2009, 2010[/size][/right]