Ghost
Admin
Posts : 28
Points : 33
Join date : 2011-05-11
 |  Subject: Psychiatric Subject Application  Sun Jun 12, 2011 10:48 pm | |
| ◦ PSYCHIATRIC SUBJECT APPLICATION ◦
________________________________________________________________________
◦ BEFORE YOU BEGIN ◦ Before you fill out an application, please make sure you read and understand the few rules laid out below. Failure to follow these simple guidelines may result in your application being removed or denied, so give yourself a few minutes to make sure you've got everything in line.
- You will need: A 250 pixels high by 250 pixels wide image of your chosen playby for the character. Sizes other than this are likely to mess with the application layout. You can use photoshop or paintshop pro for this purpose, or download a free copy of GIMP which will do the same. If all else fails, ask someone who has a copy to make one for you.
- Do not alter the application code in any way. Do not use coloured text to answer questions, or use fonts that differ greatly from the standard forum font.
- Answer every question. Even if that answer is a simple 'Not Applicable.' Try to give as much information as possible, and avoid one-line answers on questions that ask for more details and depth.
- Make sure you've read the rules and character creation. Applications that show the staff that rules and guidelines have not been read will be denied, and you will not be able to make that same character again. So take your time, familiarise yourself with the board and all of the required reading before you begin an application.
- Post your completed application in the Application Process board. Post the application as a new thread in the application process board, and title it with: Firstname Lastname. (The character's name.)
- Read the application. Before you begin, make sure you read the application over to familiarise yourself with it and to plan how you're going to answer questions. Once you've completed your application, preview it and give it a proof-read to check for spelling and grammar mistakes, and to make sure the code hasn't been broken anywhere. Your completed application should look the same as the one below, in layout.
◦ THE APPLICATION ◦ ________________________________________________________________________  ________________________________________________________________________ ◦ FIRSTNAME LASTNAME ◦  |
D.O.B: dd/mm/yyyy
AGE: 16-21
GENDER: M/F
STREET ADDRESS: House Number & Street
TOWN/CITY: Town or City
COUNTY/STATE: County, or US State
COUNTRY: Country
HEIGHT: In feet & Inches
WEIGHT: In Pounds
ETHNICITY: Caucasian/Hispanic/Asian, etc
DISTINGUISHING MARKS: Any other distinguishing marks such as birth marks, moles, piercings and tattoos.
|
________________________________________________________________________
◦ MEDICAL HISTORY ◦ Do you have any ongoing medical issues for which you require treatment or medication?:
ANSWER HERE
Are you aware of any allergies? If so, please list allergy, age of onset and any medications or treatments you require or recieve:
ANSWER HERE
Have you had any surgeries or invasive procedures in the past? If yes, please list reason and approximate age of procedure:
ANSWER HERE
Do you take any medications or supplements daily? Do you follow any treatment plans? Please list medications or treatments, and reasons below:
ANSWER HERE
Do you use tobacco, consume alcohol, or use any other drugs including street drugs and/or prescription medications not prescribed to you? If yes, please list number of packs a day, number of drinks a day, and/or drugs consumed below:
ANSWER HERE
________________________________________________________________________
◦ PSYCHIATRIC SCREENING ◦ Please describe, to the best of your ability, your emotional and mental state of wellbeing:ANSWER HERE Have you been diagnosed with any psychiatric or psychological ailments? Please list any diagnoses below, and any treatments or medications prescribed to you. Please include name of medications, dosage, and number of doses per day:ANSWER HERE Have you ever been hospitalised or referred to regular outpatient care due to these ailments or associated incidents? If so, please note where, and at roughly what age:ANSWER HERE How have these ailments affected you and your life? Are there any major life instances you feel have been directly affected by these ailments, such as suicide attempts, criminal activities, etc?:ANSWER HERE What is your social life like? Do you have many friends or relationships? How are your family relationships?:ANSWER HERE Do you believe your life circumstances have contributed to any ailments? If so, what circumstances, and why do you feel they have contributed?:ANSWER HERE If you could change one past event that has happened to you, what would it be, and why?:ANSWER HERE Do you wish to rehabilitate from your ailment(s)? If so, how do you feel this would best be accomplished?:ANSWER HERE ________________________________________________________________________
◦ ENVIRONMENTAL HISTORY ◦ Where did you grow up? Please list the location(s) and describe what it was like growing up there:
ANSWER HERE
What was your family life like? Did you spend much time with your parents? Do you have any siblings? If so, what are your relationships like?:
ANSWER HERE
What was school like? Did you have any problems? Did you enjoy school? What were your grades like?:
ANSWER HERE
Did you engage in any extracurricular activities, such as academic, artistic, or sporting clubs?:
ANSWER HERE
Have you ever been convicted of a crime or misdemeanour? If yes, please explain, list conviction, and list any sentences associated with convictions:
ANSWER HERE
Do/did you abuse controlled substances, including but not limited to tobacco, alcohol, street drugs and/or prescription medications?:
ANSWER HERE
Lastly, please tell us about yourself. How do you feel about yourself and what you have done with your life? If you have committed crimes, how do you feel about those now? What are your hopes for the future?:
ANSWER HERE
________________________________________________________________________
◦ LEGAL DOCUMENTATION ◦ Upon admission, you agree to follow all facility rules and codes of conduct, or instructions given to you by facility staff. You waive your right to medical consent and agree not to hold Brideston Pharmacokinetics and/or it's affiliates responsible for any personal harm or loss of property incurred during the course of treatment or instruction. You understand that discharge from the facility is solely at the discretion of facility administrative staff or assigned psychiatrists or psychologists. Subject, Legal Guardian, or Qualified Care Professional please sign and date below:
Firstname Lastname ◦ DD/MM/YYYY ◦
◦ APPLICATION CODE ◦
________________________________________________________________________
◦ Use This Code When Making Your Application Thread ◦ - Code:
-
[center]
[img]http://img860.imageshack.us/img860/3209/admissions.png[/img]
________________________________________________________________________
[font=Trebuchet MS][size=20][color=#648722] ◦ FIRSTNAME LASTNAME ◦ [/color][/size][/font][/center]
[table border="0"][tr][td] [img]http://img695.imageshack.us/img695/2427/appimg.jpg[/img] [/td][td]
[color=#648722][b]D.O.B:[/b][/color] dd/mm/yyyy
[color=#648722][b]AGE:[/b][/color] 16-21
[color=#648722][b]GENDER:[/b][/color] M/F
[color=#648722][b]STREET ADDRESS:[/b][/color] House Number & Street
[color=#648722][b]TOWN/CITY:[/b][/color] Town or City
[color=#648722][b]COUNTY/STATE:[/b][/color] County, or US State
[color=#648722][b]COUNTRY:[/b][/color] Country
[color=#648722][b]HEIGHT:[/b][/color] In feet & Inches
[color=#648722][b]WEIGHT:[/b][/color] In Pounds
[color=#648722][b]ETHNICITY:[/b][/color] Caucasian/Hispanic/Asian, etc
[color=#648722][b]DISTINGUISHING MARKS:[/b][/color] Any other distinguishing marks such as birth marks, moles, piercings and tattoos.
[/td][/tr][/table]
[center]________________________________________________________________________
[font=Trebuchet MS][size=18][color=#648722] ◦ MEDICAL HISTORY ◦ [/color][/size][/font][/center]
[right][color=#648722][b]Do you have any ongoing medical issues for which you require treatment or medication?:[/b][/color]
ANSWER HERE
[color=#648722][b]Are you aware of any allergies? If so, please list allergy, age of onset and any medications or treatments you require or recieve:[/b][/color]
ANSWER HERE
[color=#648722][b]Have you had any surgeries or invasive procedures in the past? If yes, please list reason and approximate age of procedure:[/b][/color]
ANSWER HERE
[color=#648722][b]Do you take any medications or supplements daily? Do you follow any treatment plans? Please list medications or treatments, and reasons below:[/b][/color]
ANSWER HERE
[color=#648722][b]Do you use tobacco, consume alcohol, or use any other drugs including street drugs and/or prescription medications not prescribed to you? If yes, please list number of packs a day, number of drinks a day, and/or drugs consumed below:[/b][/color]
ANSWER HERE
[/right]
[center]________________________________________________________________________
[font=Trebuchet MS][size=18][color=#648722] ◦ PSYCHIATRIC SCREENING ◦ [/color][/size][/font][/center]
[color=#648722][b]Please describe, to the best of your ability, your emotional and mental state of wellbeing:[/b][/color]
ANSWER HERE
[color=#648722][b]Have you been diagnosed with any psychiatric or psychological ailments? Please list any diagnoses below, and any treatments or medications prescribed to you. Please include name of medications, dosage, and number of doses per day:[/b][/color]
ANSWER HERE
[color=#648722][b]Have you ever been hospitalised or referred to regular outpatient care due to these ailments or associated incidents? If so, please note where, and at roughly what age:[/b][/color]
ANSWER HERE
[color=#648722][b]How have these ailments affected you and your life? Are there any major life instances you feel have been directly affected by these ailments, such as suicide attempts, criminal activities, etc?:[/b][/color]
ANSWER HERE
[color=#648722][b]What is your social life like? Do you have many friends or relationships? How are your family relationships?:[/b][/color]
ANSWER HERE
[color=#648722][b]Do you believe your life circumstances have contributed to any ailments? If so, what circumstances, and why do you feel they have contributed?:[/b][/color]
ANSWER HERE
[color=#648722][b]If you could change one past event that has happened to you, what would it be, and why?:[/b][/color]
ANSWER HERE
[color=#648722][b]Do you wish to rehabilitate from your ailment(s)? If so, how do you feel this would best be accomplished?:[/b][/color]
ANSWER HERE
[center]________________________________________________________________________
[font=Trebuchet MS][size=18][color=#648722] ◦ ENVIRONMENTAL HISTORY ◦ [/color][/size][/font][/center]
[right][color=#648722][b]Where did you grow up? Please list the location(s) and describe what it was like growing up there:[/b][/color]
ANSWER HERE
[color=#648722][b]What was your family life like? Did you spend much time with your parents? Do you have any siblings? If so, what are your relationships like?:[/b][/color]
ANSWER HERE
[color=#648722][b]What was school like? Did you have any problems? Did you enjoy school? What were your grades like?:[/b][/color]
ANSWER HERE
[color=#648722][b]Did you engage in any extracurricular activities, such as academic, artistic, or sporting clubs?:[/b][/color]
ANSWER HERE
[color=#648722][b]Have you ever been convicted of a crime or misdemeanour? If yes, please explain, list conviction, and list any sentences associated with convictions:[/b][/color]
ANSWER HERE
[color=#648722][b]Do/did you abuse controlled substances, including but not limited to tobacco, alcohol, street drugs and/or prescription medications?:[/b][/color]
ANSWER HERE
[color=#648722][b]Lastly, please tell us about yourself. How do you feel about yourself and what you have done with your life? If you have committed crimes, how do you feel about those now? What are your hopes for the future?:[/b][/color]
ANSWER HERE
[/right]
[center]________________________________________________________________________
[font=Trebuchet MS][size=18][color=#648722] ◦ LEGAL DOCUMENTATION ◦ [/color][/size][/font][/center]
[list][size=10]Upon admission, you agree to follow all facility rules and codes of conduct, or instructions given to you by facility staff. You waive your right to medical consent and agree not to hold Brideston Pharmacokinetics and/or it's affiliates responsible for any personal harm or loss of property incurred during the course of treatment or instruction. You understand that discharge from the facility is solely at the discretion of facility administrative staff or assigned psychiatrists or psychologists.[/size][/list]
[font=Trebuchet MS][size=16][color=#648722] Subject, Legal Guardian, or Qualified Care Professional please sign and date below: [/color][/size][/font]
[list][font=Trebuchet MS][size=18][i][u]
Firstname Lastname [/u] [/i] ◦ DD/MM/YYYY ◦
[/size][/font][/list] | |
|
