Re-Registration form for clients Contact Schakel JavaScript in je browser in om dit formulier in te vullen.Name *1. Have you received treatment at our practice before? If yes, who was your therapist at that time? *2. Do you have a preference regarding your therapist? *Yes, I would like to continue with the same therapist as before.I have a preference, but I’m open to seeing another therapist if they have availability sooner.I don’t have a preference and am open to any available therapist.Optional: Please provide any additional comments or preferences:3. What is the main reason you're seeking treatment at this time? *(For example: return of symptoms, new situation, need for follow-up, etc.)4. What symptoms or issues are you currently experiencing? *(Are these the same as before, or have they changed?)5. What do you hope to achieve through this treatment? *6. Have there been any major changes in your personal life since your previous treatment? *YesNo(e.g. work, relationships, health, loss, moving, etc.)Yes → Please explain:7. What has helped you in the past to deal with your complaints? *(This may include previous treatment, coping strategies, support from others, etc.)8. Are you currently taking any medication or receiving treatment from another healthcare provider? *YesNoYes → Please describe:9. Are you currently experiencing any crisis symptoms, suicidal thoughts, or severe emotional distress? *YesNoYes → Please explain:10. Anything else you’d like us to know?Healthcare agreement* *AgreedNot agreedAt the beginning and end of the treatment, Raja Psychologie informs the general practitioner in writing. If necessary, the psychologist consults with the general practitioner. This exchange of information is strictly confidential and falls under medical professional confidentiality.Declaration of consent* *AgreedNot agreedWhen invoicing, the care provider shares the following information with the client’s health insurer: • the main DSM category; • the basic mental healthcare profile; • the selected type of care request. No-show policy read and agreed to* *AgreedNot agreedAn appointment can always be canceled or rescheduled. During office hours, this can be done by phone, WhatsApp, or email; outside office hours, please use email. Appointments can be canceled free of charge up to 48 hours in advance. If you cancel within 48 hours before the appointment, the consultation will be charged.Seen and agreed: *AgreedNot agreedBy submitting this form, you agree to our Terms and Conditions and Privacy Policy.Verzend
