#psych form

[awfullyserotonin]

Psych Referral Form

[awfullyserotonin]

[takeabiteoutofyou]

Client Page - Dr. Lecter

Name: Irzsebet Báthory

Nicknames: Izzie

Address: 

City, State, Zip: Ystad, Sweden

PH: (36-1) 475-4405

Email: [email protected]

Occupation: Intern - Forensic photographer and full-time student

Date of Birth: 21 August 1991 

Age: 21

Gender: Female

Civil Status: Single

Have you ever been to a therapist in the past: No

Are you under medical care or supervision: No

Are you currently taking any medication: No

Do you suffer from the following:

Anxiety: A little bit

PTSD: Don't think so.

Depression: No

Bipolar: Not at all.

Schizophrenia: Maybe, who knows.

Anorexia: I eat like a horse

Bulimia Nervosa: Not really

Halluciantions: I think a little bit, just keep noticing a woman in red.

Antisocial Personality disorder: Pretty social

Multiple Personality Disorder: No

Sleep related problems: Maybe

Dementia: No

Tourettes' Syndrome: Nope

Alcohol Abuse: A little bit.

Anger Management: Decline to answer

Childhood Amnesia: No

Trichotillomania: No