Mad Alice

Asylum For Wayward Victorian Girls: Admission Form

~Name: Bloody (last name unknown)
~Date of Admission ----- ?
~Age and Sex: 23 years, female
~If any family: mother
~Occupation: student (she said)
~Habits of life: ---
~Religious Persuasion: don't answer
~Brought by Who: some people that she used to "love" (we don't know if she's able to love)
~Form of Insanity: Hysteria, Insomnia, Suicidal, Melancholia
~Supossed Cause: Herediraty
~If Hereditary: Yes
~If Suicidal: Yes (used, she said)
~If Dangerous to Others: YES!
~If Destructive to Property: no
~State of Bodily Health: good
~Mark of Violence (if any): cuts -- self inflected, tattoos