þÿ<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"> <html> <head> <meta http-equiv="content-type" content="text/html;charset=iso-8859-1"> <title>NARCONON - Aufnahmeantrag</title> <meta name="copyright" content="© 2007. NARCONON Bayern e.V. Alle Rechte vorbehalten."> <meta name="language" content="deutsch, at, de, ch, german, english, international"> <meta name="page-topic" content="Abhängigkeit, Selbsthilfeeinrichtung"> <meta name="keywords" content="Drogen, Drogenberatung, Drogenentzug, Drogensucht, Alkoholismus, Alkoholsucht, Alkoholentzug, Sucht, Suchthilfe, Selbsthilfe, Suchtkliniken, Entzug, Entzugsklinik, Kokain, Heroin, Speed, Cannabis, Ecstasy, Koks, amphetamine, abhängig, sucht beenden, codein, Alkohol, entzug schmerzfrei, beratung, therapie, therapieplatz, polamidon, abhängigkeit, abhängigkeit beenden, abstinenz, alkoholiker, droge speed, THC, crack, droge, drogenfrei, drogentherapie, ecstasy abhängig, entgiftung, extasy, hanf, Marihuana, Haschisch, illegal drogen, keine Substitution, medizinische drogen, mushrooms, narconon, Narconon Bayern, Narconon Bavaria, Narconon Tirol, Narconon Deutschland, Narconon München, Narconon Österreich, ohne Substitution, opiate, psychopharmaka, rauschgift, rehabilitation, schnellentzug, selbsthilfegemeinschaft, selbsthilfegruppe, straßendrogen, suchtberatung, suchtkrank, valium, xtc, cannabis sucht, delirium, subutex, methadon"> <meta name="description" content="Was ist NARCONON? Entstehung des Programms und die Grundlagen."> <meta name="revisit-after" content="30 days"> <meta name="page-type" content="Information"> <meta name="audience" content="alle, experten"> <meta name="Robots" content="INDEX,FOLLOW"> <style type="text/css" media="all"><!-- body { background-color: #d1d4d4; } .ds3 /*agl rulekind: base;*/ { color: #696969; font-size: 9px; } .ds4 /*agl rulekind: base;*/ { font-size: 12px; } .ds13 /*agl rulekind: base;*/ { color: #0052bd; font-size: 12px; } .ds15 /*agl rulekind: base;*/ { font-size: 9px; } .ds16 /*agl rulekind: base;*/ { color: #696969; } .ds17 /*agl rulekind: base;*/ { font-size: 11px; } #Nachfrage_fuer_Dich_Ja2 { } #Nachfrage_fuer_Dich_Nein2 { } #Nachfrage_fuer_Dich_Ja { } #Nachfrage_fuer_Dich_Nein { } #Privat { } #Staatlich { } #Wunsch_drogenfrei_ja { } #Wunsch_drogenfrei_nein { } .dsR1 /*agl rulekind: base;*/ { vertical-align: top; } #Schaltflaeche3 { } .ds19 /*agl rulekind: base;*/ { color: #0052bd; font-size: 17px; font-weight: bold; } 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</csactiondict> </head> <body onload="preloadImages();" link="#0052bd" vlink="#004084" leftmargin="0" marginheight="0" marginwidth="0" topmargin="0"> <div align="left"> <table width="864" border="0" cellspacing="0" cellpadding="0" bgcolor="white" height="141"> <tr height="68"> <td colspan="4" height="68" background="../images/drogenentzug.jpg"> </td> </tr> <tr align="left" valign="top" height="18"> <td class="Impressum" valign="bottom" width="15" height="18"></td> <td class="Impressum" valign="bottom" width="175" height="18"><span class="ds3 Impressum">NARCONON Bayern e.V.</span></td> <td class="Impressum" valign="bottom" width="479" height="18"><span class="ds3">Mitglied im Verband A<sup>.</sup>B<sup>.</sup>L<sup>.</sup>E<b> </b>International<b> </b>(Association for Better Living &amp; Education)</span></td> <td class="Impressum" valign="bottom" height="18"><span class="ds3">... für ein Leben ohne Drogen</span></td> </tr> <tr valign="top" height="55"> <td width="15" height="55"></td> <td width="175" height="55"></td> <td class="Impressum" width="479" height="55"></td> <td class="Impressum" height="55"></td> </tr> </table> <table class="dsR8" width="864" border="0" cellspacing="0" cellpadding="0"> <tr> <td valign="top" bgcolor="white" width="190"> <table border="0" cellspacing="0" cellpadding="0"> <tr valign="top" height="30"> <td align="left" width="15" height="30"></td> <td width="170" height="30"></td> <td align="right" width="5" height="30"></td> </tr> <tr valign="top" height="30"> <td align="left" width="15" height="30"></td> <td width="170" height="30"> <div align="left"> <a onmouseover="changeImages('_1c','../images/1b.gif');return true" onmouseout="changeImages('_1c','../images/1a.gif');return true" href="../index.html" target="_top"><img id="_1c" src="../images/1a.gif" alt="Home" name="_1c" height="27" width="170" border="0"></a></div> </td> <td align="right" width="5" height="30"></td> </tr> <tr valign="top" height="30"> <td align="left" width="15" 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onmouseout="changeImages('_12','../images/9a.gif');return true" href="drogen-praevention.html" target="_top"><img id="_12" src="../images/9a.gif" alt="Aufnahmefragebogen" name="_12" height="27" width="170" border="0"></a></div> </td> <td align="right" width="5" height="30"></td> </tr> <tr valign="top" height="30"> <td align="left" width="15" height="30"><img src="../images/aktiv.gif" alt="" height="27" width="9" align="absmiddle" border="0"></td> <td width="170" height="30"> <div align="left"> <a href="fragebogen.html" target="_top"><img id="_7" src="../images/7c.gif" alt="Aufnahmefragebogen" name="_7" height="27" width="170" border="0"></a></div> </td> <td align="right" width="5" height="30"></td> </tr> <tr valign="top" height="30"> <td align="left" width="15" height="30"></td> <td width="170" height="30"> <div align="left"> <a onmouseover="changeImages('_8','../images/8b.gif');return true" onmouseout="changeImages('_8','../images/8a.gif');return true" href="impressum.html" target="_top"><img id="_8" src="../images/8a.gif" alt="Kontakt" name="_8" height="27" width="170" border="0"></a></div> </td> <td align="right" width="5" height="30"></td> </tr> </table> </td> <td class="body" rowspan="2" valign="top" width="674"> <form id="Fragebogen" class="body" action="/cgi-bin/send_form_mail.php.cgi" method="post" name="Fragebogen"> <table class="dsR9" border="0" cellspacing="0" cellpadding="0" bgcolor="#e6e6e6"> <tr valign="top" height="50"> <td width="25" height="50"> </td> <td align="left" height="50"><span class="ds17"> <br> <b><font color="#a9a9a9">NARCONON</font></b></span></td> <td class="body" align="right" height="50"><span class="ds17"><br> <b><font color="#a9a9a9">Für ein Leben ohne Drogen</font></b></span></td> <td width="25" height="50"></td> </tr> <tr height="65"> <td width="25" height="65"> </td> <td class="Form" colspan="2" align="center" height="65"> <div align="center"> <span class="head"><font color="#0052bd"><span class="ds19 head1">UNVERBINDLICHER AUFNAHMEFRAGEBOGEN<br> </span><span class="subhead"><span class="ds4 head1">(auch für Angehörige zu verwenden)<br> </span></span></font></span></div> </td> <td width="25" height="65"></td> </tr> <tr> <td width="25"> </td> <td class="Form" colspan="2"> <p class="body"><span class="ds4"><input type="HIDDEN" name="r_email" value="anfrage@narconon.de"><input type="hidden" name="form_type" value="own_form"><input type="HIDDEN" name="s_subject" value="Fragebogen"><input type="HIDDEN" name="redirect" value="http://www.narconon.de/pages/danke.html"><input type="HIDDEN" name="required" value="Vorname,Nachname,Telefon,eMail" size="25"><font class="body" color="black"><br> Aufgenommen werden kann grundsätzlich jeder, der aus eigener Motivation und eigenem Willen heraus ein Leben frei von Drogen und Alkohol leben will und ein ehrliches Anliegen hat, die Hilfe von NARCONON in Anspruch zu nehmen. Grundsätzlich sollte der Antragsteller persönliche <br> Verbesserung anstreben</font></span><font class="body" color="black"><span class="ds4 copy">.<br> <br> </span></font><font color="black"><span class="ds4 copy">Diesen Fragebogen bitte möglichst vollständig ausfüllen. Alle Angaben zu Ihrer persönlichen Situation werden vertraulich und gemäß den Datenschutzrichtlinien behandelt. Je mehr Details Sie aufschreiben, desto schneller und effektiver können wir helfen. Wir melden uns baldmöglichst bei Ihnen. Daher ist es ganz wichtig, dass Sie eine Telefonnummer angeben, unter der Sie zu erreichen sind. (Felder, die mit eine Sternchen </span></font><span class="formular"><span class="ds4 copy">(*)</span></span><font color="black"><span class="fusszeile"><span class="ds4 copy"> markiert sind, bitte in jedem Fall ausfüllen).<br> <br> </span></span></font></p> </td> <td width="25"></td> </tr> <tr height="30"> <td width="25" height="30"></td> <td class="Form dsR1" colspan="2" height="30"><br> <span class="ds4"><font color="#006699" face="Arial,Helvetica,Univers,Zurich BT,sans-serif"><span class="ds4 copyfett"><span><b>ALLGEMEINE ANGABEN<br> <br> </b></span></span></font></span></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <div align="left"> <font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="copy"><span class="ds13 formular"><span>Vorname *</span></span></span></font></div> </td> <td class="Form" height="30"><input id="Nachname" type="TEXT" name="Vorname" value="" size="30" maxlength="50"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Nachname *</span></span></font></p> </td> <td class="Form" height="30"><input id="Vorname" type="TEXT" name="Nachname" value="" size="30" maxlength="50"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Straße, Hausnummer *</span></span></font></p> </td> <td class="Form" height="30"><input id="Strasse" type="TEXT" name="Strasse" value="" size="46" maxlength="46"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Wohnort (PLZ Ort) *</span></span></font></p> </td> <td class="Form" height="30"><input id="Stadt" type="TEXT" name="Wohnort" value="" size="24" maxlength="30"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Land</span></font></p> </td> <td class="Form" height="30"><input id="Land" type="TEXT" name="Land" value="" size="24" maxlength="24"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Telefon-Nr. *</span></font></p> </td> <td class="Form" height="30"><input id="Telefon" type="TEXT" name="Telefon" value="" size="50" maxlength="50"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">e-Mail-Adresse *</span></font></p> </td> <td class="Form" height="30"><input id="Eingabefeld10" type="TEXT" name="eMail" value="" size="39" maxlength="39"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Geschlecht</span></span></font></p> </td> <td class="Form1" height="30"><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds4 copy"><input id="Nachfrage_fuer_Dich_Ja2" type="RADIO" name="Nachfrage_fuer_Dich_Ja2" value="weiblich"> weiblich    <input id="Nachfrage_fuer_Dich_Nein2" type="RADIO" name="Nachfrage_fuer_Dich_Nein2" value="männlich"> männlich</span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"></td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Alter</span></span></font></p> </td> <td class="Form1" height="30"><input id="Eingabefeld10" type="TEXT" name="Alter" value="" size="15" maxlength="15"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13"><span class="ds13 formular">Ist diese</span></span><span class="ds13 formular"> Anfrage für Sie selbst?</span></font></p> </td> <td class="Form1" height="30"><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds4 copy"><input id="Nachfrage_fuer_Dich_Ja" type="RADIO" name="Anfrage" value="fuer mich selbst"> ja   <input id="Nachfrage_fuer_Dich_Nein" type="RADIO" name="Anfrage" value="fuer jemand anderen"> nein</span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Wenn nicht, geben Sie bitte den Namen des Betroffenen ein:</span></font></p> </td> <td class="Form1" height="30"><input id="Name_Person" type="TEXT" name="Betroffener" value="" size="25" maxlength="45"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">In welcher Beziehung steht der Betroffene zu Ihnen?</span></font></p> </td> <td class="Form1" height="30"><select id="Auswahlfeld2" name="Beziehung"> <option value="Freund">Freund</option> <option value="Freundin">Freundin</option> <option value="Sohn">Sohn</option> <option value="Tochter">Tochter</option> <option value="Ehemann">Ehemann</option> <option value="Ehefrau">Ehefrau</option> <option value="Vater">Vater</option> <option value="Mutter">Mutter</option> <option value="Andere">Andere</option> <option selected value=" ">bitte auswählen</option> </select></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"></td> <td class="Form" colspan="2" height="30"><br> <font color="#006699" face="Arial,Helvetica,Univers,Zurich BT,sans-serif"><span class="ds4 copyfett"><span><b>KOMSUMVERHALTEN<br> <br> </b></span></span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Um welche Droge(n) geht es?</span></font></p> </td> <td class="Form1" height="30"><select id="Droge_1" name="Droge1"> <option value="Alkohol">Alkohol</option> <option value="Amphetamine">Amphetamin</option> <option value="Cannabis">Cannabis</option> <option value="Crack">Crack</option> <option value="Ecstasy">Ecstasy</option> <option value="Haschisch">Haschisch</option> <option value="Heroin">Heroin</option> <option value="Kodein">Kodein</option> <option value="Kokain">Kokain</option> <option value="LSD">LSD</option> <option value="Marijuana">Marijuana</option> <option value="Methadon">Methadon</option> <option value="Opiate">Opiate</option> <option value="Polamidon">Polamidon</option> <option value="Speed">Speed</option> <option value="Subutex">Subutex</option> <option value="Andere">Andere</option> <option selected value=" ">Droge 1</option> </select>  <select id="Droge_1" name="Droge2"> <option value="Alkohol">Alkohol</option> <option value="Amphetamine">Amphetamin</option> <option value="Cannabis">Cannabis</option> <option value="Crack">Crack</option> <option value="Ecstasy">Ecstasy</option> <option value="Haschisch">Haschisch</option> <option value="Heroin">Heroin</option> <option value="Kodein">Kodein</option> <option value="Kokain">Kokain</option> <option value="LSD">LSD</option> <option value="Marijuana">Marijuana</option> <option value="Methadon">Methadon</option> <option value="Opiate">Opiate</option> <option value="Polamidon">Polamidon</option> <option value="Speed">Speed</option> <option value="Subutex">Subutex</option> <option value="Andere">Andere</option> <option selected value=" ">Droge 2</option> </select>  <select id="Droge_1" name="Droge3"> <option value="Alkohol">Alkohol</option> <option value="Amphetamine">Amphetamin</option> <option value="Cannabis">Cannabis</option> <option value="Crack">Crack</option> <option value="Ecstasy">Ecstasy</option> <option value="Haschisch">Haschisch</option> <option value="Heroin">Heroin</option> <option value="Kodein">Kodein</option> <option value="Kokain">Kokain</option> <option value="LSD">LSD</option> <option value="Marijuana">Marijuana</option> <option value="Methadon">Methadon</option> <option value="Opiate">Opiate</option> <option value="Polamidon">Polamidon</option> <option value="Speed">Speed</option> <option value="Subutex">Subutex</option> <option value="Andere">Andere</option> <option selected value=" ">Droge 3</option> </select> </td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Wie wird die Droge konsumiert?</span></font></p> </td> <td class="Form1" height="30"><select id="Droge_1" name="Konsumform"> <option value="geschnupft">geschnupft</option> <option value="geschluckt">geschluckt</option> <option value="gespritzt">gespritzt</option> <option value="geraucht">geraucht</option> <option value="getrunken">getrunken</option> <option selected value=" ">bitte auswählen</option> </select> </td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Beginn des Drogenkonsums?</span></font></p> </td> <td class="Form1" height="30"><input id="Wann_begonnen" type="TEXT" name="Beginn_Drogenkonsum" value="" size="15" maxlength="18"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13"><span class="ds13 formular">In wel</span></span><span class="ds13 formular">chem Alter zeigten sich die ersten Änderungen im Verhalten?</span></font></p> </td> <td class="Form1" height="30"><input id="Alter_Veraenderungen" type="TEXT" name="Beginn_Auswirkungen" value="" size="15" maxlength="18"></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Welche Veränderungen brachte der Drogenkonsum mit sich?</span></font></p> </td> <td class="Form1" height="30"><textarea id="Veraenderungen" name="Veränderungen" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Gab es außergewöhnliche oder problematische Ereignisse? (z.B. Verletzungen, Todesfälle, Missbrauch o.ä.)</span></font></p> </td> <td class="Form1" height="30"><textarea id="Ereignisse" name="Ereignisse" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Ausführliche Beschreibung der Drogenvergangenheit:</span></font></p> </td> <td class="Form1" height="30"><textarea id="Drogenvergangenheit" name="Drogenvergangenheit" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Welche Probleme verursacht der Drogenkonsum?</span></font></p> </td> <td class="Form1" height="30"><textarea id="Probleme_der_Sucht" name="Probleme" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Wie wirkt sich der Drogenkonsum auf das Umfeld aus (Familie, Freunde, Bekannte, Beruf)?</span></font></p> </td> <td class="Form1" height="30"><textarea id="Familienprobleme" name="Umfeld" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td class="dsR10" width="25"> </td> <td class="Form dsR10" colspan="2" valign="middle"><br> <font color="#006699" face="Arial,Helvetica,Univers,Zurich BT,sans-serif"><span class="ds4 copyfett"><span class="ds4"><span><b>VERGANGENE BEHANDLUNGEN<br> <br> </b></span></span></span></font></td> <td class="dsR10" width="25"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Gab es jemals eine Drogenbehandlung? (Wenn ja, wann und welche?)</span></font></p> </td> <td class="Form1" height="30"><textarea id="Drogenbehandlung" name="Drogenbehandlung" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">War es ein privates oder ein staatlich gefördertes Programm?</span></font></p> </td> <td class="Form1" height="30"><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds4 copy"><input id="Privat" type="RADIO" name="Behandlung" value="privat finanziert"> Privat    <input id="Staatlich" type="RADIO" name="Behandlung" value="staatlich gefördert"> Staatlich</span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Welche Wirkung hat diese Behandlung erzielt?</span></font></p> </td> <td class="Form1" height="30"><textarea id="Wirkung" name="Wirkung" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" colspan="2" height="30"><br> <font color="#006699" face="Arial,Helvetica,Univers,Zurich BT,sans-serif"><span class="ds4 copyfett"><span><b>MEDIZINISCHES<br> <br> </b></span></span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Gibt es bekannte Krankheiten? (Wenn ja, welche?)</span></font></p> </td> <td class="Form1" height="30"><textarea id="Wirkung" name="Krankheiten" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Gab es jemals eine Diagnose hinsichtlich psychischer Störungen? (Wenn ja, welche?)</span></font></p> </td> <td class="Form1" height="30"><textarea id="Wirkung" name="Psychische_Störung" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Wurden Medikamente gegen psychische Störung eingenommen? (Wenn ja, welche?)</span></font></p> </td> <td class="Form1" height="30"><textarea id="Wirkung" name="Psychopharmaka" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" colspan="2" height="30"><br> <font color="#006699" face="Arial,Helvetica,Univers,Zurich BT,sans-serif"><span class="ds4 copyfett"><span><b>RECHTLICHES<br> <br> </b></span></span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds13 formular">Gibt es offene rechtliche Angelegenheiten (offene Verfahren etc)?</span></font></p> </td> <td class="Form1" height="30"><textarea id="Wirkung" name="Rechtliches" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" colspan="2" height="30"><br> <font color="#006699" face="Arial,Helvetica,Univers,Zurich BT,sans-serif"><span class="ds4 copyfett"><span><b>ABSCHLIESSENDE ANGABEN<br> <br> </b></span></span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Haben Sie bzw. der Betroffene den ausdrücklichen Wunsch von Alkohol/Drogen weg zu kommen?</span></span></font></p> </td> <td class="Form1 dsR1" height="30"><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="ds4 copy"><input id="Wunsch_drogenfrei_ja" type="RADIO" name="Will_von_Drogen_wegkommen" value="ja"> ja    <input id="Wunsch_drogenfrei_nein" type="RADIO" name="Will_von_Drogen_wegkommen" value="nein"> nein</span></font></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Gibt es irgendwelche Umstände, die eine Hilfe verhindern könnten?</span></span></font></p> </td> <td class="Form1" height="30"><textarea id="Hinderungsgruende" name="Hindernde_Umstaende" rows="4" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Wie geht es Ihnen bzw. dem Betroffenen jetzt im Moment? Bitte ausführlich beschreiben. Fügen Sie jegliche Fragen und Informationen hinzu die wir wissen sollten (beste Zeit für einen Anruf, usw.)</span></span></font></p> </td> <td class="Form1" height="30"><textarea id="Zustand" name="Gegenwaertiger_Zustand" rows="8" cols="50" wrap="PHYSICAL"></textarea></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form" height="30"> <p><font face="Verdana,Tahoma,Arial,Helvetica,sans-serif"><span class="formular"><span class="ds13 copy">Wie haben Sie uns gefunden?</span></span></font></p> </td> <td class="Form1" height="30"><select name="Werbung_durch" size="1"> <option value=" ">bitte auswählen</option> <option value="Suchmaschine">Suchmaschine</option> <option value="Bannerwerbung">Bannerwerbung</option> <option value="Link auf anderer Website">Link auf anderer Website</option> <option value="Flugzettel">Flugzettel</option> <option value="Broschüre">Broschüre</option> <option value="Kleinanzeige">Kleinanzeige</option> <option value="Süddeutsche Zeitung">Süddeutsche Zeitung</option> <option value="Frankfurter Allgemeine">Frankfurter Allgemeine</option> <option value="Süddeutsche Zeitung">Süddeutsche Zeitung</option> <option value="Zeitungsartikel">sonstige Zeitungsartikel</option> <option value="Hausarzt">Hausarzt</option> <option value="Freunde/Bekannte">Freunde/Bekannte</option> </select></td> <td width="25" height="30"></td> </tr> <tr height="30"> <td width="25" height="30"> </td> <td class="Form1" colspan="2" height="75"><br> <br> <span class="ds4 copy">&gt;&gt;  <input id="Schaltflaeche3" type="SUBMIT" name="Fragebogen" value="absenden">  &lt;&lt;    </span><span class="ds4 fusszeile">(zum Absenden diesen Button drücken)</span></td> <td width="25" height="30"></td> </tr> <tr height="35"> <td width="25" height="35"> </td> <td class="Form" colspan="2" height="35"> </td> <td width="25" height="35"></td> </tr> </table> </form> </td> </tr> <tr> <td valign="bottom" bgcolor="white" width="190"></td> </tr> 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