Dratis Institute Patient Registration Form

Full Name:

Alias (if patient presents with multiple personalities or masking and prefers a different name):

Age:

Sex:

Sexual orientation (optional):

Eye colour:

Hair colour:

Blood type:

Family member, guardian or legal POA admitting patient (if patient is admitting themselves, please write full name):

Reason for admittance:

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Admitted patient has shown signs of the following disorders (check any/all that apply)*:

-Acute stress disorder [ ]
-Antisocial personality disorder [ ]
-Amnestic disorder (amnesia) [ ]
-Anxiety disorder [ ]
-Asperger syndrome [ ]
-Autism [ ]
-Autophagia [ ]
-Avoidant personality disorder [ ]

-Bipolar disorder(i or ii) [ ]
-Body dysmorphic disorder [ ]
-Borderline personality disorder [ ]

-Claustrophobia [ ]
-Catatonic disorder [ ]
-Cotard delusion (walking corpse syndrome) [ ]

-Depersonalization disorder [ ]
-Depression (chronic) [ ]
-Dissociative identity disorder (multiple personality disorder) [ ]
-Delusional disorder [ ]

-Eating disorder (anorexia nervosa, bulimia nervosa, binge eating, etc.) [ ]

-Gender identity disorder [ ]

-Mood disorder [ ]

-Narcissistic personality disorder [ ]

-Obsessive compulsive disorder [ ]

-Perfectionism [ ]
-Phobic disorder [ ]
-Psychosis (encompassing) [ ]
-Pyromania [ ]

-Sadomasochism [ ]
-Schizoaffective disorder or schizophrenia [ ]
-Sleep disorder (including insomnia, nightmare disorder or sleep anxiety, DSPS, night terrors, sleepwalking, etc.) [ ] (diagnosis will be confirmed through therapies)
-Substance or polysubstance abuse/dependence (including alcohol, inhalants, narcotics, etc.) [ ]

-Trichotillomania [ ]

*As defined by the DCM and ICD

For any other disorder or disturbance, please list below:
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Please list any other information you deem important below:
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Signature:

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By signing this admittance form it is understood that the admitted patient will be subject to therapy and treatment in order to improve their quality of life and mental health until deemed safe for release (be it in parallel to themselves or others). Patient records will be kept private and confidential unless a consultation is needed by an assisting medical professional.

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