General Questionnaire

 

 

This online service is provided free of charge as a public service and all information received from clients is confidential.

 

If you need immediate help phone us at 0041(0)78 815 33 17.

 

Response time using the questionnaire below is usually 24 to 48 hours, and is in the form of a confidential e-mail.

 

In some instances, we may phone or email you personally to better assess the situation.

 

When we phone we only identify ourselves to the contact person listed below, and will advise all others that this is a personal call and will not disclose who we are or why we are calling.

 

It is important that you answer the following questions as accurately as possible.

 

We will provide assistance even if all of the information requested below is not provided. 

 

And remember all information you provide is covered by our strict client confidentiality code.

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* Required information.
Name
Your email address *
Your daytime phone number
Your evening phone number
Your address
Person you wish to help *
If not for yourself, please give the name, age and exact relationship to you
Does the subject want help?
Primary problem *
Secondary problem
Tertiary problem
If you selected 'other' in any of the 3 selections above, please describe
How does the person obtain money for their addiction (if relevant)
Can the person travel?
Describe any personal/family problems the person has.
Please describe any legal problems the person has.
Please describe the overall behaviour and condition of the person.
Is there any diagnosed medical condition? (please describe)
Is there any diagnosed mental disorder? (please describe)
Is the person on any medication for the above? *
If yes, what medication?
Has the person ever attempted recovery before? By which method(s)? *
If the person has attemped recovery before, please describe
Were the above privately or state- funded?
Is there anything else you would like us to know?
© 2009 Küsnacht Practice - One to One Addictions Treatment, Psychiatry and Psychotherapy