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

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 neutral

First name*

Last name*

Infix

Address*

Housenumber

Zip Code + City*

Place*

Date of birth*

Phone*

E-mail address*

BSN number*

In case you don't have a BSN number (Social Security Number), please enter nine zero's.

Make sure to provide the number to us at a later time, since without a BSN number,
the cost can't be referred to your health insurer

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

Can you specify what you require help with?*

Do you have any further details to add?

Reffered by*

Name referrer*

Name Grip Mental Health practitioner at your GP's

Preferred location

Preference method of treatment*

Preferred day and or time

Healthcare insurer*

Attach your referral letter (optional, max 4MB)
You can also upload the email confirmation from your GP of the referral through the Zorgdomein system. Be aware that the referral is mandatory in order to be invited for a first appointment.

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

Click here to open our privacy policy

I am aware that on my email address I will receive general information and information regarding appointments. Treatment content and medical information will be send by Grip through coded email*

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