Registration form

Upon receipt of your registration form we will contact you within one working day.

(*) = Required field





Gender: FemaleMale

First name:(*)

Last name: (*)

Email address: (*)

Phone number: (*)

Street and house number: (*)

Postal code: (*)

Town: (*)

Date of birth: (*)

General Practitioner: (*)

Health insurance company: (*)

Are you currently in treatment elsewhere? (*) YesNo

I’m registering for: (*)
Basic Mental Health CareSpecialized Mental Health Care

Description of the problem:

Optional: You can upload your referral letter (maximum file size 1MB, only PDF or JPEG files allowed):

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By using this form you agree with the storage and handling of your data.

* In case your GP has referred you for treatment within the basic mental health care domain (Generalistische Basis GGZ/ GBGGZ) and after the intake it is concluded that therapy within the specialized mental health care domain (Gespecialiseerde GGZ/ GGGZ) is indicated, please be aware that there is probably a waiting period for both our practice as elsewhere within the specialized mental health care domain (Gespecialiseerde GGZ/ GGGZ).