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.

Firstname *

Surname *

Street Address *

ZIP / Postal Code *

City *

Country *

Nationality *

Country of Birth *

Phone number (include country code please!) *Please include your country code (For example: +34 152112233)

Email address *

Relationship *

Firstname *

Surname *

Gender *

Male
Female

Street Address *

ZIP / Postal Code *

City *

Country *

Nationality *

Phone number (include country code please!) *For our records only, not to be contacted. Please include your country code (For example: +34 152112233)

Email address *For our records only, not to be contacted

Date of Birth *

Country of Birth *

Personal (marital) status/living conditions *

School attendance *

Yes
No

Employed *

Yes
No

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