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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 Studentenwerk 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




    male     female     other


Postal Code





Marital status:

    single     married      divorced


How did you hear of us?

Internet

Poster/Flyer

other counselling services

Lecturer

Friends

Doctor

is known / public


Study information





 

number of semesters:

including:
BA
Master
State examination
BA teaching degree
Master teaching degree
Phd
Other

At the time I am:

student university

student of applied sciences (FH/PFH/HAWK)

staff member



Studies are financed by:

parents / partner

BAföG (federal funding grant for education)

scolarship

loan

own job


Information on parents and siblings

Mother

years old
passed away when I was years old
learned profession:  
current occupation:  

Father

age years old
passed away when I was years old
learned profession:  
current occupation:  

Separation of parents?
at the time I was years old

and lived after separation with     mother     father     both     others     alone

 

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. Apply the following classification:

 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        
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 Studentenwerk Göttingen.

 


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