Patient Application Template

• Please do not change any of the app coding. I have tried to make it as simple to navigate as I can without compromising the feel I was going for. If you need any help with broken bits of code, catch me in the cbox or shoot me a PM.
  
• If you change the font or colour for your answers, make sure the font or colour is easy to read against the darker background and is not too small or too big. Some of us are old a crotchety and the old peepers don't work as well as they used to.
  
• The top part of the app is in character, and written, not spoken. So there should not be any actions or anything like that in the application.
  
• The application is geared towards having a psychiatrist or psychologist fill it out ( your referring mental health professional, remember? ) however, you can have your patient fill it out if you wish. If a psych is filling it out, please note their name and status somewhere near the top of the application so we know who's filling it out. You can also have both fill out different portions! Just make sure to differentiate the voices by using italics and noting who is which part.
  
• We do not accept WIP applications. They disappoint the fidgety staff who want to read all of your app in one go. So if you have to take a break from your app, please save it somewhere else, or email it to yourself, etc.
  
• Please don't let your application image exceed 400px by 400px in size.
  
• Please title your application: Firstname Lasntame. Please do not include nicknames, middle names, or salutations.
  
• When you are ready for your app to be reviewed, post it as a new topic in the Application Processing board. Please be patient with staff after you have posted it, as we would like to RP too and might not get to it immediately.
  
• Lastly, make sure you read the walkthrough provided below, as our application style might be tricky to navigate your first time! The walkthrough notes are in red.
  

Gender:
Date of Birth: mm/dd/yyyy
Age:
Height:
Weight:
Ethnicity: Caucasian/Hispanic/Asian/ etc.
Hair Colour:
Eye Colour:
Distinguishing Marks: Scars (where they are and what they're from), moles, tattoos, birthmarks, and piercings go here!


Please check one of the following:
[  ] Transferred from another facility.
[  ] Referred from outpatient care.
[  ] Self Admitted.

Current Address: If they are currently in another facility please provide the name and address.
Ward: A, B, C, or D. Please check our usergroups to determine which your character belongs in.
Primary Diagnosis:
Secondary Diagnosis/es:

Please mark if you have a history of any of the following:


 

___________________________________ [x] Asthma replace space with small x [  ] Alcoholism [  ] Allergies [  ] Arthritis [  ] Back Pain or Injuries [  ] Broken Bones [  ] Bronchitis [  ] Chronic Pain [  ] Chronic Colds, Flu, Etc.

___________________________________ [  ] Diabetes [  ] Epilepsy [  ] Headaches [  ] Head Injuries [  ] Heart Problems [  ] Recreational Drug Use [  ] Surgeries [  ] Tobacco Use [  ] Other (Please Specify)

Please Explain Any Marked Above: Answer Here If marking medical conditions, you must explain the condition(s) and list age of onset as well as any treatments that were received fully for each. Beware of adding any/too many if they don't make sense for your character. If marking alcohol, tobacco, or drug use, please list roughly how many drinks/packs a day and/or what drugs were taken and when. Note: psychiatric conditions do not fall under the medical category. Those come later in the app.

Please mark if you currently suffer from any of any of the following:


 

___________________________________ [ ] Asthma [ ] Alcoholism [ ] Allergies [ ] Arthritis [ ] Back Pain or Injuries [ ] Broken Bones [ ] Bronchitis [ ] Chronic Pain [ ] Chronic Colds, Flu, Etc.

___________________________________ [ ] Diabetes [ ] Epilepsy [ ] Headaches [ ] Head Injuries [ ] Heart Problems [ ] Recreational Drug Use [ ] Surgeries [ ] Tobacco Use [ ] Other (Please Specify Below)

Please Explain Any Marked Above: Answer Here



Please mark the appropriate boxes for the following: Take into account everything included in the functioning category when you pick an answer. You may also add notes underneath each category if you would like to specify what about each category they struggle with or excel at. For example, if they're good at cooking but their personal grooming is terrible, they still need intervention, but you can note that they don't need help cooking.

Social Functioning: (Ability to make and maintain appropriate social and personal relationships. Ability to interact appropriately in social situations and relationships.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed

Executive Functioning: (Ability to manage time and perform basic self management tasks like attending classes/work and completing tasks and daily chores as expected and in a timely fashion.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed

Emotional Functioning: (Ability to manage and appropriately express emotions in the moment. Possesses appropriate coping skills, and is able to identify own emotions in the moment and afterwards.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed

Life Skills: (Ability to complete basic living tasks necessary for independent living, such as housekeeping, self grooming, bookkeeping, cooking, and appropriate nutrition management.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed


What recent event(s) led to the patient's current need for hospitalization?: Answer Here Please answer these questions as thoroughly as you can. This is where your character's backstory and personality come out in the application, so we want to know as much as there is to know! (It doesn't have to be a novel, just enough for us to see them as a fully fleshed out person with a history. Some answers will be shorter than others and that's okay!)

Were there any prior hospitalizations for these or similar diagnoses?: Answer Here

Please describe the patient's emotional state at this time: Answer Here

What past behaviours, moods, or incidents led to the patient's diagnosis/es: Answer Here

Please explain any life factors contributing to the diagnosis/es: Answer Here

What was the patient's childhood like?: Answer Here Where were they born? Where did they grow up and what was it like there and at home? What was the family dynamic like? Childhood is important in psych history, so give us everything you can!

What are the patient's personal and social relationships like?: Answer Here

What are the patient's family relationships like?: Answer Here

How did the patient function in school and what subjects did they prefer?: Answer Here Don't forget to note if they graduated HS or not!

What are the patient's interests and/or hobbies?: Answer Here

Does the patient have a criminal record? If yes, what offences are listed and what were the penalties?: Answer Here

What are the patient's primary problem behaviours at this time?: Answer Here

What are the patient's short term goals?: Answer Here

What are the patient's long term life goals goals?: Answer Here

Additional Information/Notes: Answer Here This is for any resident information you couldn't put in the rest of the application. It's basically a "Tell Us About Yourself" section, but in shrink form. You could talk about the resident's personality, summarise their life, etc etc. Whatever you want to put here to clarify or add to the app.


Out of Character Notes/Secrets/Information/Etc.: Answer Here Buyer Beware! This section is for bits and bobs that aren't known by the character's previous shrinks or by echo mountain. However, the meat of your character should not go here! We need most of your information in the in character section, otherwise Echo Mountain wouldn't be able to process their application and won't know enough about them. Only use this section for naughty little tidbits they've been keeping a secret, or for other OOC notes you think are important to the character but can't be on the IC app!

Player Nickname:
Chatango Name: Yes, you'll need one of these for the chatbox!
Character Playby:

Code:


[center][img]http://s25.postimg.org/5cbise3hr/appheadermid.png[/img]


[size=22]Firstname Lastname[/size]

Application Image Goes Here in IMG tags.[/center]

[list]
[b]Gender:[/b]
[b]Date of Birth:[/b]
[b]Age:[/b]
[b]Height:[/b]
[b]Weight:[/b]
[b]Ethnicity:[/b]
[b]Hair Colour:[/b]
[b]Eye Colour:[/b]
[b]Distinguishing Marks:[/b]


[b]Please check one of the following:[/b]
[  ] Transferred from another facility.
[  ] Referred from outpatient care.
[  ] Self Admitted.

[b]Current Address:[/b]

[b]Ward:[/b]
[b]Primary Diagnosis:[/b]
[b]Secondary Diagnosis/es:[/b][/list]


[center][size=18]Medical History[/size]
‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗[/center]

[b]Please mark if you have a [u]history[/u] of any of the following:[/b]
<table><tr><td> ___________________________________
[  ] Asthma
[  ] Alcoholism
[  ] Allergies
[  ] Arthritis
[  ] Back Pain or Injuries
[  ] Broken Bones
[  ] Bronchitis
[  ] Chronic Pain
[  ] Chronic Colds, Flu, Etc.
</td>
<td> ___________________________________
[  ] Diabetes
[  ] Epilepsy
[  ] Headaches
[  ] Head Injuries
[  ] Heart Problems
[  ] Recreational Drug Use
[  ] Surgeries
[  ] Tobacco Use
[  ] Other (Please Specify)
</td>
 </tr>
</table>
[b]Please Explain Any Marked Above:[/b] Answer Here

[b]Please mark if you [u]currently[/u] suffer from any of any of the following:[/b]
<table><tr><td> ___________________________________
[ ] Asthma
[ ] Alcoholism
[ ] Allergies
[ ] Arthritis
[ ] Back Pain or Injuries
[ ] Broken Bones
[ ] Bronchitis
[ ] Chronic Pain
[ ] Chronic Colds, Flu, Etc.
</td>
<td> ___________________________________
[ ] Diabetes
[ ] Epilepsy
[ ] Headaches
[ ] Head Injuries
[ ] Heart Problems
[ ] Recreational Drug Use
[ ] Surgeries
[ ] Tobacco Use
[ ] Other (Please Specify Below)
</td>
 </tr>
</table>
[b]Please Explain Any Marked Above:[/b] Answer Here


[center][size=18]Psychiatric History[/size]
‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗[/center]

[b]Please mark the appropriate boxes for the following:[/b]

[b]Social Functioning:[/b] (Ability to make and maintain appropriate social and personal relationships. Ability to interact appropriately in social situations and relationships.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed

[b]Executive Functioning:[/b] (Ability to manage time and perform basic self management tasks like attending classes/work and completing tasks and daily chores as expected and in a timely fashion.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed

[b]Emotional Functioning:[/b] (Ability to manage and appropriately express emotions in the moment. Possesses appropriate coping skills, and is able to identify own emotions in the moment and afterwards.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed

[b]Life Skills:[/b] (Ability to complete basic living tasks necessary for independent living, such as housekeeping, self grooming, bookkeeping, cooking, and appropriate nutrition management.)
[ ] Fully Functioning
[ ] Some Staff Support Needed
[ ] Clinical Intervention & Staff Support Needed


[b]What recent event(s) led to the patient's current need for hospitalization?:[/b][/color] Answer Here

[b]Were there any prior hospitalizations for these or similar diagnoses?:[/b] Answer Here

[b]Please describe the patient's emotional state at this time:[/b] Answer Here

[b]What past behaviours, moods, or incidents led to the patient's diagnosis/es:[/b] Answer Here

[b]Please explain any life factors contributing to the diagnosis/es:[/b] Answer Here

[b]What was the patient's childhood like?:[/b] Answer Here

[b]What are the patient's personal and social relationships like?:[/b] Answer Here

[b]What are the patient's family relationships like?:[/b] Answer Here

[b]How did the patient function in school and what subjects did they prefer?:[/b] Answer Here

[b]What are the patient's interests and/or hobbies?:[/b] Answer Here

[b]Does the patient have a criminal record? If yes, what offences are listed and what were the penalties?:[/b] Answer Here

[b]What are the patient's primary problem behaviours at this time?:[/b] Answer Here

[b]What are the patient's short term goals?:[/b] Answer Here

[b]What are the patient's long term life goals goals?:[/b] Answer Here

[b]Additional Information/Notes:[/b] Answer Here

[center][size=18]Out of Character Section[/size]
‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗‗[/center]

[b]Out of Character Notes/Secrets/Information/Etc.:[/b] Answer Here

[list]
[b]Player Nickname:[/b]
[b]Chatango Name:[/b]
[b]Character Playby:[/b][/list]