8/18/2019 Insanity Certificate
2/2
• Dementia Præcox• Delusions• Paranoia• psychogenic Fugue•
Dysphoric Mania• Dissociative Identity Disorder• involutional
melancholia• Post-Traumatic Stress Disorder• Dyssomnia•
Neurasthenia• morbid whimsicality• Trichotillomania• Amnesia•
Catatonia• Depersonalization disorder
• Tillinghast’s Complaint• Xenopharmacophilia• Monomania•
Hallucinations • visual • auditory• pica
(elaborate) ...................................................................•
Obsessive-Compulsive Disorder• Panic disorder• general cacochymy•
Separation Anxiety• Hysterical Paralysis• Repetitive Self-Harm
Syndrome• abject denial• Sleep Terror disorder
• psychasthenia• intermittent explosive disorder• Multi-infarct
Dementia• Epistomophobia• Agateophobia• Nyctophobia• Other Phobia
(Specify) .................................................•
Megalomania• Paragraphia• Paraphilia (Specify)
.........................................................• reactive
attachment disorder• Enamorate delirium (chump syndrome)•
phrenitis• Selective Mutism• Other
(Specify) ....................................................................
Cerficaon of Insanity
condition is (Check one):
• Temporary • treatable • incurable
certificant is Harmful to (check all that apply):
• self • others
certificate No.
in testimony whereof:
asylum Director
Know ye ,
whereas ______________________________________ of
______________________________________________
has been examined by the staff of this institution and found to
be sorely afflictedwith the mental condition(s ) noted
below;* now, therefore, this
is duly issued this ______ day of
_____________ , in the year _______ .* check
all that apply:
form HPLHS IC-08 ©2007 HPLHS, Inc. All rights reserved.
Walter Forsythe
Arkham, Massachusetts
29th April 1927
650901
Vincent Headrick
