Registration form

Please read our registration procedure carefully before registering with us.

Please note: you will always receive a confirmation email on the same day of your registration. If this is not the case, your registration did not come through properly. Please try again.

REGISTRATION FORM FOR PRESCREENING

Your information details will be stored and processed in a secured environment on a private owned server and will not be accessible to third parties.

Prefix*

mr ms/mrs

First name*

Last name*

Infix

Address*

Housenumber

Zip Code + City*

Place*

Date of birth*

Phone*

E-mail address*

What is the reason for your registration (what are your symptoms?)*

What could be the possible cause of your symptoms?*

Wat are the consequences of your symptoms and how do they affect your daily life?*

When did your symptoms start?*

Have you previously had any psychological symptoms? And if so, were you given a diagnosis?*

Have you previously been treated for psychological symptoms? And if so, what type of treatment did you receive?

Do you ever consider ending your life? If so, one of our psychologists will contact you by phone to discuss and determine what type of care is necessary on short term.*

Have you experienced any major life events that you consider generally important to mention or that are important to mention in context of your symptoms (such as a divorce/fire/natural disaster/sexual abuse/physical violence/accident/death of a close relative/witness of a traumatic event), and if so, which? *

What would you like to achieve through treatment? When would treatment feel like a success according to you?*

Do you have any additional comments?

Reffered by*

Name referrer*

Name Grip Mental Health practitioner at your GP's

Preferred location

Preferred day and or time

Healthcare insurer*

Referral letter*

Attach your referral letter (optional, max 4MB)

I hereby authorize Grip Psychologen to process the above personal data in accordance with the privacy policy .*

Security image. You must enable images to submit entry

Enter what you see:
(Case sensitive)

Fields marked (*) are required.

More information?

Grip Psychologen

email: info@grippsychologen.nl

Phone number: 085-0471147

You can reach us by phone every working day between 8:30am and 12:30pm and between 1:30pm and 4pm. You can also leave a voicemail message. We will call you back within one day.

In case of EMERGENCY:

Please note: in case of emergency, we cannot take on your registration. In this case, we advise you to contact your own GP. They can refer you to urgent psychiatry.

If you urgently need help outside of office hours, you can contact the following organisations yourself:

Spoedeisende Psychiatrie Amsterdam (Urgent Psychiatry Amsterdam)

www.spoedeisendepsychiatrieamsterdam.nl

020 523 54 33

GP post for urgent medical treatment Amsterdam

www.huisartsenpostenamsterdam.nl

088 00 30 600

Suicide prevention

www.113.nl

0900 – 0113