Self-registration

By completing the form below, you will provide us with further important information. On this basis, we can reserve a therapy place for you.

We will then invite you to a personal preliminary consultation, during which a final decision on admission will be made. If you wish, you are welcome to bring a trusted person with you to this consultation.

Personal details

Title*

First name*

Last name*

Maiden name(optional)

Street, No.*

Postal code*

Place of residence*

Phone*

Mobile(optional)

Email*

Date of birth *

Marital status(optional)

Number of children(optional)

Children's age(optional)

Occupation(optional)

Address of family doctor(optional)

Family doctor's phone number(optional)

I agree that PSA may contact my family doctor.*

Health insurance(optional)

Insurance number(optional)

Insurance*

How did you hear about us?*

Family / social network

Who do you live with (partner, children, parents)?(optional)

Work situation

Please describe your work situation or other daily structure(optional)

Health

Do you suffer or have you suffered from a serious physical illness?(optional)

Do you suffer or have you suffered from a serious mental illness?(optional)

Have you had any accidents or serious operations?(optional)

Are you scheduled for surgery or major medical examinations?(optional)

Alcohol consumption

Since when has your alcohol consumption been problematic?(optional)

What do you consume most and how much?(optional)

How often do you consume?(optional)

Other addictive substances

Cigarettes: How many per day?(optional)

Cannabis: Since when, how often?(optional)

Other substances (non-prescription medications, drugs): which ones, how often?(optional)

Previous treatments

Have you already sought help for your alcohol problem?*

If so, where/with whom?(optional)

When?(optional)

Official measures

Is there a guardianship?*

Has your driver's license ever been revoked?(optional)

If so, how often?(optional)

When was the last time?(optional)

Therapy goals

We would like to support you in actively addressing your difficulties in various areas. What would you like to change? What are your goals for therapy?(optional)

Privacy

Upload file(optional)

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