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Registration form

Your confidence is important to us!
The transmission of your data takes place via an encrypted connection. Access to the data is only available to the employees of the Psychological Counselling Service (PSB). You are engaging in psychological counselling at the PSB of the Studierendenwerk Göttingen. Your entire data is subject to professional secrecy and is treated strictly confidential. Collegial professional exchange (supervision/intervision) within the team of counsellors is taking place only in an anonymised way.
Please ensure that you complete all sections of the form!

Personal details

Fields with an * are required fields.

Name of Counsellor: *

Surname: *

First Name: *

Date of birth: (Format: 23.07.1999) *

Gender: *

male

female

other

Not specified

Street, No.: *

Postal Code: *

City: *

Phone: *

E-Mail: *

Nationality: *

Marital status: *

single

married / in a civil partnership

divorced

Number of children: *

How did you hear of us? *

Internet/Social Media

Poster/Flyer

other counselling services

Lecturer

Friends

Doctor

was already known to me

Study information

Field of study (free text): *

Faculty: *

Faculty 2: *

Current stage of study: *

Number of semesters in current stage of study: *

Total number of semesters: *

At the time I am: *

student at the University of Göttingen

student at the PFH

student at the HAWK

student at the Gesundheitscampus

staff member / trainee

Studies are financed by: *

parents / partner

BAföG (federal funding grant)

scholarship

loan

own job

Information on parents and siblings

Mother / 1st Guardian

Age:
Deceased:
Highest educational attainment:

Father / 2nd Guardian

Age:
Deceased:
Highest educational attainment:

Separation of parents?

Yes

No

at the time I was ... years old:

Siblings (number):

Please deliberate which of the here listed problems you are currently suffering from. Mark the box that correlates the frequency of prevalence within the last 14 days. Please do not skip any questions, even if you find it difficult to answer.

	never	sometimes	often	always
Problems with self esteem
Conflicts with my family
Illness/death of close friends/relatives
Problems socialising / in groups
Partnership problems
Strong strain because of children
Problems regarding social/occupational future
Problems with cultural identity
Problems coping with stress
Sexual problems / sexual orientation
Anxiety / worries / restlessness
Depression / melancholy
Exhaustion / fatigue
Eating disorder
Alcohol-/drug-abuse / addiction problems
Physical illness / pain
Suicidal thoughts and fantasies about suicide
Obsessive compulsive imaginations and behaviours
Aggression
Known psychiatric disorder
Problems with housing situation
Financial difficulties
Excessive computer gaming / use of internet
Procrastination (frequent postponement of important things)
Problems with work organisation and time management
Learning / concentration / attention disorder
Problems with lecturer/professor/tutor
Test anxiety
Fear of public speaking
Writer's block
Dissatisfaction with subject of study
Graduation problems

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By pressing the OK-Button I agree to save my data as declared in the information sheet according to section 13 of the EU-data protection regulation and the data protection declaration of the Studierendenwerk Göttingen.

I have taken note of the data protection information and agree to the processing of my data *

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