VISITATION FORM

DATE:

please read all questions carefully before answering.

1. what is your reason for visitation?

2. what is your gender?

3. does your family have any history?

4. is this your first time visiting?

5. will this be your last time visiting?

6. please select all that apply to you:

extremely spotty memory, or no memory at all

flashbacks or visions more than once a week

constantly feeling on edge or like bad things will happen, or, conversely, being uncharacteristically bold/relaxed/unworried

crisis of faith

presence of unfamiliar internal voices

noticeable changes in eye color more than twice a week, or development of heterochromia

unable to keep a steady grip on objects

not needing to or being unable to sleep for more than 72 hours

not needing to or being unable to eat for more than 4 days

7. do you know where you're going?

8. this is no easy road.

9. i know you're probably anxious to get on.

10. would you believe me if i said i was sorry?