PERSONAL DETAILS

Name

Date of Birth

Male Female Other

Contact e-mail

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Area of Cultural Practice Bad Painting good painting colour photography video installation performance art criticism bricolage poetry

Preferred Language English German Italian Russian Japanese one you made up

Physical Appearance

Cultural or Spiritual Needs

Physical Abilities and Needs

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Circumstances Surrounding your Need for a Cure

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CLINICAL SYMPTOMS

Anxiety/Fears (if you have any) are they about: commercial failure moral compromise death sexual inadequacy creative inadequacy financial ruin losing your looks

describe them in detail

Depressive Symptoms

I find my symptoms:

interesting

potential subject matter

just depressing

Sleep

only when chemically aided

as much as possible

fitful, plagued by horrid dreams

Eating

never have time

borderline eating disorder

too much

only when someone else pays

 

Problem behaviour aggression temper outbursts antisocial behaviour inappropriate sexual activity all of the above

Psychotic features

Relationship Problems

Developmental History/Problems

Alcohol/Drug abuse occasional user regular user frequent binges rarely sober vegan, lives on fruit juice

Attitude towards Society owes me a living I make art for the people I make art for myself bunch of philistines no such thing as Society I'm an important member of it making Art is just a job Artists are Seers and Visionaries I'm on the dole

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