{"id":1589,"date":"2020-07-19T16:46:32","date_gmt":"2020-07-19T16:46:32","guid":{"rendered":"http:\/\/psychezwangerschap.nl\/?page_id=1589"},"modified":"2026-04-28T12:57:32","modified_gmt":"2026-04-28T12:57:32","slug":"registration-form","status":"publish","type":"page","link":"https:\/\/psychezwangerschap.nl\/en\/contact\/registration-form\/","title":{"rendered":"Registration form"},"content":{"rendered":"\n<p class=\"has-background\" style=\"background-color:#f2e0ab\">Clients can only register for treatment by completing the registration form below. Referrers can fill in the registration form together with their client.<\/p>\n\n\n\n<p><strong>No guarantee can be derived from the waiting times stated below.<\/strong><br><br>The waiting time for an\u00a0<strong>online<\/strong>\u00a0treatment with an English speaking psychologist <strong>contract free or a contract with a label of Achmea\u00a0<\/strong>is about\u00a0<strong>2 months.<\/strong><\/p>\n\n\n\n<p>The waiting time for a\u00a0<strong>face to face\u00a0<\/strong>treatment with an English speaking\u00a0<strong>contract free \u00a0<\/strong>psychologist is about\u00a0<strong>2 months.<\/strong><br><br>Read more about a psychologist without any contracts: <strong><a href=\"http:\/\/www.contractvrijepsycholoog.nl\/\" target=\"_blank\" rel=\"noreferrer noopener\">www.contractvrijepsycholoog.nl<\/a><br><\/strong><br>The waiting time for an\u00a0<strong>online<\/strong>\u00a0treatment with an English speaking psychologist <strong>contracted other than Achmea<\/strong>\u00a0is about\u00a0<strong>8 months.<\/strong><br><br>The waiting time for a\u00a0<strong>face to face<\/strong>\u00a0treatment with an English speaking <strong>contracted\u00a0<\/strong>psychologist\u00a0<strong>(other than Achmea)<\/strong>\u00a0is at least\u00a0<strong>12 months.<\/strong><br><br><strong>If you need urgent help, please contact your doctor. Or perhaps <a href=\"https:\/\/arkin.nl\" target=\"_blank\" rel=\"noreferrer noopener\">Arkin<\/a> or <a href=\"https:\/\/www.ggzingeest.nl\" target=\"_blank\" rel=\"noreferrer noopener\">inGeest<\/a> can see you sooner.<\/strong><\/p>\n\n\n\n<p>After processing your application, you will be contacted by e-mail within three days.<b>&nbsp;<\/b>For urgent questions, please send an email to <a href=\"mailto:info@psychezwangerschap.nl\">info@psychezwangerschap.nl<\/a>.<br><br>The <a href=\"https:\/\/aws.cdn-plugandpay.com\/media\/tenants\/26048\/202512\/111b6f26a7ef7b907d418ecf0a6c54fa-psychezwangerschap-leaflet-a5-engels.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Resilient Parenting Prevention Program<\/a> will launch in 2026. This program does not replace psychological treatment but can be part of it. This program is fully covered by Zilveren Kruis (for 1 star or higher).<br><br><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_6' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>Please use this form to register with one of our therapists. Fill in the form as completely as possible. The fields marked with an asterisk are obligatory. <\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/en\/wp-json\/wp\/v2\/pages\/1589' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_21\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_21'>URL<\/label><div class='ginput_container'><input name='input_21' id='input_6_21' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_6_21'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_6_3' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_4'>E-mail:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_6_4' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Why you need our help:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_18'><li class='gchoice gchoice_6_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Pregnancy'  id='choice_6_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_18_1' id='label_6_18_1' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Post partum'  id='choice_6_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_18_2' id='label_6_18_2' class='gform-field-label gform-field-label--type-inline'>Post partum<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Fertility'  id='choice_6_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_18_3' id='label_6_18_3' class='gform-field-label gform-field-label--type-inline'>Fertility<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Treatment preference<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_17'><li class='gchoice gchoice_6_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Online treatment'  id='choice_6_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_17_1' id='label_6_17_1' class='gform-field-label gform-field-label--type-inline'>Online treatment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Face to face treatment'  id='choice_6_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_17_2' id='label_6_17_2' class='gform-field-label gform-field-label--type-inline'>Face to face treatment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='No preference, I like both treatments'  id='choice_6_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_17_3' id='label_6_17_3' class='gform-field-label gform-field-label--type-inline'>No preference, I like both treatments<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_19'>Prefered place for treatment (only at face to face appointments)<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_6_19' class='large gfield_select'     aria-invalid=\"false\" ><option value='Amersfoort' >Amersfoort<\/option><option value='Amsterdam' >Amsterdam<\/option><option value='Arnhem' >Arnhem<\/option><option value='Broek in Waterland' >Broek in Waterland<\/option><option value='Gorssel' >Gorssel<\/option><option value='Heiloo' >Heiloo<\/option><option value='Leiden' >Leiden<\/option><option value='Noordwijkerhout' >Noordwijkerhout<\/option><option value='Rijen' >Rijen<\/option><option value='Utrecht' >Utrecht<\/option><\/select><\/div><\/li><li id=\"field_6_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Reimbursement:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_20'><li class='gchoice gchoice_6_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Psychologist with contract (100% reimbursed but longer waiting time)'  id='choice_6_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_1' id='label_6_20_1' class='gform-field-label gform-field-label--type-inline'>Psychologist with contract (100% reimbursed but longer waiting time)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Psychologist without contract (partly reimbursed but shorter waiting time)'  id='choice_6_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_20_2' id='label_6_20_2' class='gform-field-label gform-field-label--type-inline'>Psychologist without contract (partly reimbursed but shorter waiting time)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_10'>Insurer and policy:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_6_10' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_7'>Choose your therapist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select'  aria-describedby=\"gfield_description_6_7\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Secretary' selected='selected'>Secretary<\/option><option value='Judith Buursema-Grave' >Judith Buursema-Grave<\/option><option value='Merith Cohen de Lara (client stop)' >Merith Cohen de Lara (client stop)<\/option><option value='Romy Damhuis' >Romy Damhuis<\/option><option value='Sascha van Ede - Boes' >Sascha van Ede - Boes<\/option><option value='Anne-Marie Hubers (Amersfoort)' >Anne-Marie Hubers (Amersfoort)<\/option><option value='Eva van Ormondt (online)' >Eva van Ormondt (online)<\/option><option value='Saskia Overing-Bots' >Saskia Overing-Bots<\/option><option value='Marion Stronks (Elst - Gelderland)' >Marion Stronks (Elst - Gelderland)<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_7'>Choose your therapist from the list. If you have no preference choose 'Secretary'. You will then be assigned to the first available therapist.<\/div><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Referrer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_6_8' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Comments or questions:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_6_13' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_15'>What is the color of fresh snow?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_6_15' type='text' value='' class='medium'  aria-describedby=\"gfield_description_6_15\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_6_15'>This question is asked you to identify you as a real person. 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