Registration form

Please read the application procedure carefully before applying.

Please note that you will always receive confirmation (on the same day of registration) by email that you have registered. If this is not the case, your registration has not reached us. Please try again.
You will only be called if there are any ambiguities in your registration form.

It is important to keep a close eye on your mailbox. We will send you regularly messages about your treatment program.

REGISTRATION FORM

These data are securely processed and stored within our own system and on our own server. The data are not accessible to third parties.

Referral letter including medication summary present?

Yes
No
I fully pay for my treatment process myself. Grip does not declare the costs to my health insurance. And I will not declare the costs of my sessions to my health insurance either.

You cannot register until you have a referral letter. Once you have this in your possession, you are able to register via the website.

Are you in possession of a Healthcare Domain Number*

Ja
Nee

Your Healthcare Domain Number*

If you have another type of referral letter, please upload it here*

Salutation*

mr ms/mrs neutral

First name*

Last name*

Infix

Address*

House no.

Zip code*

Location*

Date of birth*

Phone number*

E-mail address*

Document Type*

Document number*

BSN number*

What is the reason for your application (what are your complaints)?*

What is your request for help?*

Do you have any other details to add?

Reffered by*

Name of referring physician / general practitioner*

Name of referrer Grip POH-er

When are you available for appointments*

I have no preference for particular days or times (I am always available)
I am not available at……

Please note: Grip Psychologen works Blended. That means a combination of video call appointments and face-to-face appointments. Your appointments will be scheduled based on your completed availability. It is therefore important that you correctly communicate your availability to us. Scheduling is easier for us if you are flexible in terms of location, video calls and treatment times.
Should your availability change, please notify the secretary as soon as possible.

Passing on scheduled vacation.

If you are going on vacation, in which weeks are you not available for sessions?

Health insurance company*

I hereby give permission to Grip Psychologists to process the above personal data in accordance with the privacy policy.*

Click here to access our privacy policy

I acknowledge that my email address will be used for treatment appointments and general information. Content and medical information will be emailed from Grip via encrypted mail.*

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Field marked with a (*) are obligatory.

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