INTAKE FORM 1 - Information: Contact Person 2- Information Of Participant 3 - Family and Parental Authority 4 - Problems of Participant Information Of Contact Person First Name Surname Street Address ZIP Code City Country Nationality Country of Birth Phone Number (include country code please!) Email Address Relationship Father Mother Partner Guardian Family Guardian Participent Info First Name Surname Street Address ZIP Code City Country Nationality Country of Birth Phone Number (include country code please!) Email Address Relationship Father Mother Partner Guardian Other Family Guardian Family and Parents Info Are Parents Divorced? Yes No Current composition family participant? Are there any special circumstances or details that should be mentioned regarding the family origin? Participent's Problem(s) Addiction Gaming Alcohol Cannabis and/or marihuana Hard drugs Gambling Sex Social media None of the above Other Mental health issue(s) ADHD ODD CD PDDNOS Depression Eating disorder(s) Other None of above Behavioural disorder Family problems Very low self-esteem Early school leaving Authority problem/problems with authorities Lying, manipulating, cheating Self-harm Other None Of Above Can you describe the problem(s) of the participant in a few sentences? Who is the family doctor (Last Name) Street Address ZIP / Postal Code City Country Phone number (include country code please!) Is the participant currently in treatment with a therapist, psychologist or psychiatrist? Yes No Has the participant previously experienced psychiatric hospitalization? Yes No Does the participant use any (prescription) drugs? Yes No Are there any other relevant issues we should know about? How did you find us? Google Media (magazines/tv) Trough families, friends, or former clients Social Media Others SHOW SUMMARY Some required Fields are emptyPlease check the highlighted fields. Submit Previous Step Next Step
