Name SurnamePlace of Birth / YearAgeGenderMarital StatusChoose...MarriedSingleDivorcedMother Alive or Deceased?Choose...AlivePassed awayWhen Did She Pass Away?Father Alive or Deceased?Choose...AlivePassed awayWhen Did He Pass Away?Phone NumberE- mailFaculty / DepartmentStudent NumberYour last semester GPAPast SuccessChoose...GoodAverageBadContact Information / Relationship Degree of the Person to be Called in Case of EmergencyWhere / With Whom Do You Live During Your University EducationHealth InformationDo you have a chronic disease?Choose...YesNoHave you met with a psychologist or psychiatrist before?Choose...YesNoIf you have, what were the reasons for this meeting? Please specify.How long were your sessions? Please indicate in months or years.Are you currently taking any psychiatric medications?Choose..YesNoIf your answer is Yes, please specify the name of the drug/drugs.Please select the options below that you have used before or currently use.Choose...Cigarettesand AlcoholDrugI have never used any of them before/I do not use themHow did you decide to apply to PDRAM ?Choose...My own decisionFamily requestA friend's recommendationA recommendation from an expert outside the universityPlease briefly state your reason for applying to PDRAMHow long has your problem been going on? When did you first feel it?Does your problem occur daily, weekly or less frequently? How often do you experience this situation?Does your problem vary in severity? Does it sometimes get worse or does it always stay the same?Do certain situations or events cause your problem to occur? If so, what are those triggers?What solutions or remedies have you tried before for this problem? How effective were these solutions? Send