Registration form

GGZ Veenendaal provides mental health care for people with psychological problems. Our help is covered by your health insurance, but you need a letter of referral from your family doctor. Our therapists speak Dutch, English and Polish.

How do you register for treatment?

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Send this form

Please fill in the form. You also need a letter of referral from your family doctor in order to be registered. You can upload it here, send it to us, or hand it over peronally.

We make an appointment

When possible we will send you an invitation for one or two intake sessions. We will discuss treatment and make a treatment plan.

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Start treatment

Soon after the intake session we start treament. You will recieve an invitation for one or more sessions by mail, or we can call you.

Fill in the form below to register

"(required)" geeft vereiste velden aan

DD slash MM slash JJJJ
Your address(required)
From your identifcation document
Identification document(required)
Did you already discuss this with your family doctor?(required)
You are referred to
Name contact person(required)
in case of emergency
compulsary by the Dutch government
compulsary by the Dutch government
compulsary by the Dutch government
Wilt u onderstaande vragen beantwoorden? Op die manier kunnen wij een betere inschatting maken óf en op welke manier wij een passende behandeling kunnen bieden. Mocht u liever telefonisch overleggen voordat u deze vragen beantwoordt dan horen we dat graag van u.
Did you recently see, smell, hear or experience things other people do not experience?(required)
Psychotic symptoms
Suicide attempts(required)
Did you try to commit suicide during the last month?
Addictions(required)
Are you addicted to alcohol, drugs, of for instance porn or gambling?
Have you been abusive LAST YEAR?(required)
Like conflicts or arguments that got out of hand and led to physical fight.
Agreement(required)
I agree that the therapist who screens the referrals and the therapists involved in my treatment are allowed to read my prior medical files from GGZ Veenendaal when applicable.
You can upload it here: select files and click Send.
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Max. bestandsgrootte: 64 MB, Max. aantal bestanden: 5.