DYSTHYMIA (a klance fan-fiction)

5. Keith

//TRIGGER WARNING: SELF-HARM, PURGING.//

"Date: June 12, 20XX

PATIENT'S INF0RMATION:

Name: Keith Kogane City: Muskogee State: Oklahoma

Mobile Number: 999-909-9901

I'd like a courtesy appointment reminder:

sent to my email address

texted to my cell phone

Sex: Male Date of Birth: October 23, 20XX Age: 17 Marital Status: None

RESPONSIBLE PARTY (statements will be sent to):

Name: Takashi Shirogane City: ______________________________ State: _________

Mobile Number: ________________________

Sex: ________ Date of Birth: __________________ Age: ______ Marital Status: _________ Relationship to patient: ______________________________

SECOND PARENTAL GUARDIAN (will be contacted as well if needed):

Name: _______ City:____________________________State:____________

Mobile Number: _______________

Sex:_________Date of Birth: _____________ Age:_______Marital Status:_____________

Subscriber's ID: ____________________________ I, the undersigned, accept financial responsibility for payment of all fees at the time of the visit, unless other arrangements have been made. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the release of any information regarding my/my child's condition or treatment to my insurance company. AUTHORIZATION TO PAY INSURANCE BENEFITS TO THE PROVIDER: I hereby authorize the payment of insurance benefits from my insurance company to my provider. SIGNED: __________________________________________ (patient, or parent if patient is a minor)

DATE: ___________________

Name of patient:___________________________________________________

DATE: ______________________

Chief concern: Please describe the main difficulty that has brought you to see me: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Prior Treatment 1. Have you ever received psychological or counseling services before?

No Yes

If yes: When? From whom? For what? With what results? _________________________ _____________________________________________________________________ ____________________________________________________________________

2. Have you ever taken medications for psychiatric or emotional problems? No Yes

If yes, please list medications taken and briefly describe the results

________________________________________________________________________________________________________________________________________________________"

It goes on like that for two more pages, blurry inked lines and yes or no questions with a signature at the end. The due date is written in sloppy blue scrawl at the top.