Claudia: Medical Form.

IN PATIENT REFERRAL FORM TO PSYCHIATRIC INSTITUTION.

NAME: CLAUDIA GLASS.

DOB: (UNKNOWN ESTIMATED YEAR 1940).

GENDER: FEMALE.

ADDRESS: UNKNOWN.

MARITAL STATUS: UNMARRIED.

TEL NO: UNKNOWN.

FAMILY/ FRIEND NAME: QUENTIN SMITH.

RELATIONSHIP: FRIEND.

ADDRESS: 49 WILLOW CLOSE, JUPITER, FLORIDA.

CONTACT NO: -

REFERRING HOSPITAL: -

WARD: -

REFERRING WARD DOCTOR: -

CONTACT DETAILS: - 

DATE OF ADMISSION: 12.03.1959

DATE OF REFERRAL: - 
                                                                                                                                                                       
                                                                                                                                                                          

VOLUNTARY:  -       INVOLUNTARY:  YES.       ASSISTED:  -      URGENT:  -


FORMS: (please tick those forms accompanying patient)

INVOLUNTARY:

Masters in Health Care Administration:

Level 04: -

Level 05 x2: -

Level 06: -

Level 07: FAIRLY DANGEROUS.

Level 11: -

MEDICAL HISTORY:
Unknown in full, has been to doctors about mental illness but never received a follow up appointment. Doctors notes describe erratic behaviour and trouble sleeping.

CURRENT MEDICAL TREATMENT: 
none.

Taking inspiration from images I have found on the internet I decided to make a little character background profile for Claudia based on the beginning of her time in the mental asylum. I wanted her to be able to have a fitting back story and so I made this admissions form for Claudia who has just been checked into Briar Cliff Sanitarium. The form basically describes how Claudia has had no treatment no one really knows that much about her and Quentin found her and checked her into the institution: he didn't leave a contact number and he doesn't know much about her family relationships. The doctors do not know the full extent and severity of her illness/ possession, I think this sets up the background for my story well.