Intake Form

You can register by filling in the intake form below. Upon receipt, we will contact you to schedule a personal intake interview. Please take a look at our current waiting times.

During the interview, we will examine whether our programme is suitable for the problem(s) you and your child currently experience. It is important to bring the following documents along (without them, the intake cannot take place):

  • Valid ID Card/passport of participant
  • Previous medical/psychological/other reports
  • List of medication from pharmacy
  • Medical ID Card or health insurance policy

If you have any additional questions, our Case Management is ready to assist you Monday to Friday from 9:00 a.m. to 10:00 p.m. and on Saturday and Sunday from 10:00 a.m. to 4:00 p.m. (GMT +1) via phone number: +31 (0)85 02 01 222

All your questions, registration documents and personal information will always be dealt with in a confidential manner and with the utmost care.

 
Information: Contact Person
Name
Address
Please include your country code (For example: +34 152112233)
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Information: Participant
Name


Address
For our records only, not to be contacted. Please include your country code (For example: +34 152112233)
For our records only, not to be contacted




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Family and Parental authority


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Problems of participant
General information family doctor
Please include your country code (For example: +34 152112233)






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Registration data
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