Registration form

Please read the application procedure carefully before applying.

Take notice: you currently cannot register when you are insured with Zilveren Kruis, CZ and ASR, due to yearly budget limitations for 2024 for these insurers. You can register again IN 2025

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.  

For completeness we would like to point out that content sent to us and from us by email, is not secured. For sending emails and/or documents with privacy-sensitive information we use another secure email platform

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.

A valid referral letter contains at least:

• Your name and BSN number
• It should be addressed to a practice for psychologists
• Name and AGB-code of referrer
• A date that is no older than 9 months ago

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 (ZD) Number*

Yes
No

Healthcare Domain Nr (e.g. ZD123456789)*

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*

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Phone number*

E-mail address*

Document Type*

Passport/ID proof Drivers license Residence document

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?

Referred by*

General practitioner Company doctor Mental Health Nurse Practitioner Self referred

Name of referring physician / general practitioner*

Name of referrer Grip POH-er

Janna ter Denge Peter Oude Wesseling Sanne Visser

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*

How did you hear about our organization?*

Through a search engine (e.g. Google)
Through your general practitioner
Through any other professional
Other, specifically:

(for example, a(n) acquaintance/friend/family member)

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.*

Enter what you see: (Case sensitive)

Field marked with a (*) are obligatory.