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Data

Name

Family name

Studentnumber

I have an appointment with

Date of appointment

Reason for seeking support

Description of your complaints

What would you like to change (what do you want to work on)

Are you registered with a general practitioner

Yes

Registration with a general practitioner is mandatory in the Netherlands. It is advisable to arrange your registration with a general practitioner before your first appointment date with the student psychologist.

General well-being

I feel overburdened

yes

Rate on a scale from 1: slightly to 10: severe

I feel down / depressed

yes

Rate on a scale from 1: slightly to 10: severe

I feel anxious

yes

Rate on a scale from 1: slightly to 10: severe

I have trouble concentrating / I am forgetful

yes

I have sleep problems

yes

Do you drink alcohol?

yes

How many glasses per week?

Do you use drugs?

yes

What kind and how much per week?

How many hours per day do you spend on the internet?

Is this more than you want to?

yes

I have recently visited the general practitioner or a specialist

yes

I have health related issues

yes

I use medication

yes

Have you ever been treated for psychological issues before?

yes

Do you have realatives who suffer from psychological issues?

yes

Relationships and personal contacts

I have problems with my parents/within my family

yes

I have issues with (intimate) friendships

yes

I have problems with making or maintaining contacts with others

yes

I have problems with adapting to my (new) study environment

yes

I have another issue with relationships or contacts

yes

Study(progress)

I stress because of the workload of my study program

yes

Rate on a scale from 1: slightly to 10: severe

I am falling behind on my planning

yes

I have a study delay

yes

I am in doubt about my choice of studies / career

yes

I have other issues with my study progress

yes

Rules & regulations

I have special circumstances that (may) influence my studies

yes

I have financial issues due to study delay, internship or unforeseen situations

yes

I am in danger of receiving a negative binding recommendation / MoMi decision

yes

I have problems or a conflict within my program

yes

I have other issues regarding rules & regulations

yes