{"id":2746,"date":"2023-05-08T11:07:10","date_gmt":"2023-05-08T08:07:10","guid":{"rendered":"https:\/\/www.anasa.com.gr\/erotimatologio-enilikon\/"},"modified":"2023-08-02T13:47:31","modified_gmt":"2023-08-02T10:47:31","slug":"adult-questionnaire","status":"publish","type":"page","link":"https:\/\/www.anasa.com.gr\/en\/adult-questionnaire\/","title":{"rendered":"Adult Questionnaire"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2748-o1\" lang=\"el\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/2746#wpcf7-f2748-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2748\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"el\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2748-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"uacf7-form-2748\"><div class=\"erothmatologio-efhvon vc-border\">\n\n\t<div class=\"vc-row \">\n\t\t<div class=\"vc-col-12 vc-text-center mb-40\"><h4>ADULT QUESTIONNAIRE<\/h4><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12 vc-text-right\"><label> DATE: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-form\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date date-form\" min=\"2026-11-07\" max=\"2026-11-07\" step=\"3\" aria-required=\"true\" aria-invalid=\"false\" value=\"2026-11-07\" type=\"date\" name=\"date-form\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20\">\n\t\t<div class=\"vc-col-6\"><label> CONTACT TELEPHONE: <span class=\"wpcf7-form-control-wrap\" data-name=\"tel-epikoinonias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-epikoinonias\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label> EMAIL: <span class=\"wpcf7-form-control-wrap\" data-name=\"email-epikoinonias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-epikoinonias\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>FULL NAME: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-onomateponumo\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-onomateponumo\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<!--\n\t<div class=\"vc-row mb-40 mt-20\">\n\t\t<div class=\"vc-col-12\"><p class=\"vc-text-center\">Please answer the following questions<\/p><\/div>\n\t<\/div>\n\t-->\n\n\t<div class=\"vc-row vc-border-b\">\n\t\t<div class=\"vc-col-4\"><label> AGE <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ilikia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-ilikia\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ilikia\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-4\"><label> GENDER <span class=\"wpcf7-form-control-wrap\" data-name=\"text-fulo\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-fulo\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-fulo\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-4\">\n\t\t\t<label for=\"radio-asfalisi\">DO YOU HAVE INSURANCE?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-asfalisi\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio field-asfalisi\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-asfalisi\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-asfalisi\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>HOW DID YOU HEAR ABOUT ANASA? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-pou-mathate-tin-anasa\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-pou-mathate-tin-anasa\"><\/textarea><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-6\"><label>WHAT PROBLEM ARE YOU EXPERIENCING? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-provlima\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-provlima\"><\/textarea><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>WHEN DID IT START? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-pote-xekinise-to-provlima\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-pote-xekinise-to-provlima\"><\/textarea><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-6\"><label>WEIGHT: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-varos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-varos\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>HEIGHT: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ipsos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ipsos\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><label>HAVE YOU LOST WEIGHT IN THE PAST? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-xanei-varos-sto-parelthon\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-xanei-varos-sto-parelthon\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-6\"><label>HOW MUCH? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-poso-varos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-poso-varos\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>BY WHAT METHODS? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-tropoi-meiosis-varous\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-tropoi-meiosis-varous\"><\/textarea><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><label>DO YOU HAVE BINGE-EATING EPISODES? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-epeisodia-uperfagias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-epeisodia-uperfagias\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><label>HOW MANY DURING THE DAY? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-suxnotita-uperfagias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-suxnotita-uperfagias\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>PLEASE DESCRIBE AN EXAMPLE OF A BINGE-EATING EPISODE: <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-paradeigma-uperfageias\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-paradeigma-uperfageias\"><\/textarea><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20\">\n\t\t<div class=\"vc-col-12\"><label>DO YOU USE LAXATIVES? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-xrisi-kathartikon\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-xrisi-kathartikon\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>DO YOU VOMIT? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-kanete-emetous\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-kanete-emetous\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>DO YOU HAVE ANY GYNAECOLOGICAL PROBLEMS? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-gunaikologika-provlhmata\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-gunaikologika-provlhmata\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>HOW DO YOU FEEL ABOUT YOUR BODY? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-pos-niothete-me-to-soma-sas\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-pos-niothete-me-to-soma-sas\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"parakolouthisi-parelthon\">HAVE YOU PREVIOUSLY BEEN SEEN BY A PSYCHOLOGIST AND\/OR PSYCHIATRIST?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"parakolouthisi-parelthon\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"parakolouthisi-parelthon\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"parakolouthisi-parelthon\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><p><strong>IF YES:<\/strong><\/p><\/div>\n\t\t<div class=\"vc-col-6\"><label>WHEN? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-parakolouthisi-pote\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-parakolouthisi-pote\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>FOR HOW LONG? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-parakolouthisi-diastima\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-parakolouthisi-diastima\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"radio-psuxiatriki-diagnosi\">HAVE YOU BEEN GIVEN A PSYCHIATRIC DIAGNOSIS?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-psuxiatriki-diagnosi\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-psuxiatriki-diagnosi\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-psuxiatriki-diagnosi\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>IF YES, WHICH DIAGNOSIS (IF KNOWN)? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-psuxiatriki-diagnosi-poia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-psuxiatriki-diagnosi-poia\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><label>ARE YOU CURRENTLY TAKING OR HAVE YOU PREVIOUSLY TAKEN MEDICATION? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-farmakeutiki-agogi\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-farmakeutiki-agogi\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>IF YES, WHICH MEDICATION? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-farmakeutiki-agogi-poia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-farmakeutiki-agogi-poia\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"radio-nosileia\">HAVE YOU EVER BEEN HOSPITALISED IN A PSYCHIATRIC CLINIC OR A PSYCHIATRIC DEPARTMENT OF A HOSPITAL?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-nosileia\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-nosileia\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-nosileia\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><p><strong>IF YES:<\/strong><\/p><\/div>\n\t\t<div class=\"vc-col-6\"><label>WHEN? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-nosileia-pote\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-nosileia-pote\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>FOR WHAT REASON? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-nosileia-logos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-nosileia-logos\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<p><em>IF AVAILABLE, PLEASE BRING TO YOUR FIRST VISIT TO THE ANASA DAY CENTRE YOUR HOSPITAL DISCHARGE DOCUMENTATION, INCLUDING THE ICD-10 DIAGNOSIS, MEDICATION AND INSTRUCTIONS, AS WELL AS THE NAME OF YOUR TREATING PHYSICIAN AS A CONTACT PERSON, IN ORDER TO FACILITATE THE THERAPEUTIC ASSESSMENT.<\/em><\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"radio-parakolouthisi-simera\">ARE YOU CURRENTLY BEING SEEN BY A PSYCHOLOGIST AND\/OR PSYCHIATRIST?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-parakolouthisi-simera\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-parakolouthisi-simera\" value=\"PSYCHOLOGIST\" \/><span class=\"wpcf7-list-item-label\">PSYCHOLOGIST<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-parakolouthisi-simera\" value=\"PSYCHIATRIST\" \/><span class=\"wpcf7-list-item-label\">PSYCHIATRIST<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-parakolouthisi-simera\" value=\"BOTH\" \/><span class=\"wpcf7-list-item-label\">BOTH<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-parakolouthisi-simera\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"radio-diatrofika-provlimata\">HAVE YOU NOTICED EATING-RELATED PROBLEMS OR AN EATING DISORDER?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-diatrofika-provlimata\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-diatrofika-provlimata\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-diatrofika-provlimata\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><p><strong>IF YES:<\/strong><\/p><\/div>\n\t\t<div class=\"vc-col-6\"><label>BEFORE OR AFTER ANOTHER PSYCHIATRIC DIAGNOSIS? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-diatrofika-prin-meta-diagnosi\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-diatrofika-prin-meta-diagnosi\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>BEFORE OR AFTER STARTING PSYCHIATRIC MEDICATION? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-diatrofika-prin-meta-agogi\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-diatrofika-prin-meta-agogi\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"radio-psuxotropes-ousies\">HAVE YOU USED OR DO YOU CURRENTLY USE PSYCHOACTIVE SUBSTANCES?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-psuxotropes-ousies\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-psuxotropes-ousies\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-psuxotropes-ousies\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><p><strong>IF YES:<\/strong><\/p><\/div>\n\t\t<div class=\"vc-col-6\"><label>WHICH SUBSTANCES? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ousies-poies\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ousies-poies\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>WHEN? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ousies-pote\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ousies-pote\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-6\"><label>FOR HOW LONG? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ousies-diastima\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ousies-diastima\" \/><\/span><\/label><\/div>\n\t\t<div class=\"vc-col-6\"><label>IS THERE ACTIVE USE AT PRESENT? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ousies-energi-xrisi\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ousies-energi-xrisi\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>HAVE YOU PARTICIPATED IN AN ADDICTION TREATMENT OR REHABILITATION PROGRAMME? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ousies-programma-apexartisis\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ousies-programma-apexartisis\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<label for=\"radio-alli-therapeftiki-diadikasia\">ARE YOU CURRENTLY ACTIVELY PARTICIPATING IN ANOTHER THERAPEUTIC OR PSYCHOTHERAPEUTIC PROCESS?<\/label>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-alli-therapeftiki-diadikasia\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-alli-therapeftiki-diadikasia\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-alli-therapeftiki-diadikasia\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t<div class=\"vc-col-12\"><label>IF YES, PLEASE SPECIFY: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-alli-therapeftiki-prosdiorismos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-alli-therapeftiki-prosdiorismos\" \/><\/span><\/label><\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<p>I confirm the accuracy and correctness of the above information, which I completed on <span class=\"wpcf7-form-control-wrap\" data-name=\"date-end\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date date-form\" min=\"2026-11-07\" max=\"2026-11-17\" step=\"0\" aria-required=\"true\" aria-invalid=\"false\" value=\"2026-11-07\" type=\"date\" name=\"date-end\" \/><\/span>, and I sign below.<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mt-60\">\n\t\t<div class=\"vc-col-4\">\n\t\t\t<hr>\n\t\t\t<p>Full Name \u2013 Signature<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mt-20\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<span>(Note: This completed form will be provided to you for signature when you visit the ANASA Day Centre for your first appointment.)<\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mt-60\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-448\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-448\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I confirm that I am over 18 years of age.<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-40\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-618\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-618\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I have read the <a href=\"https\\:\/\/www\\.anasa.com.gr\/el\/gnwstopoiisi-dilwsi-enilikou\/\" target=\"_blank\">Privacy Notice<\/a> regarding the collection and processing of personal data and, by submitting my information and that of my minor child, I give my consent.<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row mb-20\">\n\t\t<div class=\"vc-col-12\">\n\t\t\t<p><strong>The clinical team of the ANASA Day Centre will receive and evaluate the completed questionnaire, and the ANASA Day Centre Secretariat will contact you to schedule your first appointment with a specialist at our Centre.<\/strong><\/p>\n\t\t\t<p><strong>Thank you very much. We will contact you soon!<\/strong><\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"vc-row\">\n\t\t<div class=\"vc-col-12\"><input class=\"wpcf7-form-control has-spinner wpcf7-submit vc-field-submit\" type=\"submit\" value=\"SUBMIT\" \/><\/div>\n\t<\/div>\n\n<\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"acf":[],"_links":{"self":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2746"}],"collection":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/comments?post=2746"}],"version-history":[{"count":3,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2746\/revisions"}],"predecessor-version":[{"id":2751,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2746\/revisions\/2751"}],"wp:attachment":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/media?parent=2746"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}