{"id":1235,"date":"2023-04-20T12:03:33","date_gmt":"2023-04-20T12:03:33","guid":{"rendered":"https:\/\/estherschuller.com\/?page_id=1235"},"modified":"2023-08-07T11:44:13","modified_gmt":"2023-08-07T11:44:13","slug":"aanmeldformulier","status":"publish","type":"page","link":"https:\/\/estherschuller.com\/?page_id=1235","title":{"rendered":"Aanmeldformulier (N.B.: alleen invullen als we reeds contact gehad hebben en een afspraak hebben gemaakt)"},"content":{"rendered":"<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 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data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Aanmeldformulier<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1235' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_3_27\" class=\"gfield gfield--type-NamePrefix_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_27'><span class='gform-field-label__text'>Voorletters *<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_3_27' type='text' value='' class='large'  aria-describedby=\"input_3_27_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_28\" class=\"gfield gfield--type-FirstName_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'><span class='gform-field-label__text'>Voornaam *<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='large'  aria-describedby=\"input_3_28_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_29\" class=\"gfield gfield--type-LastName_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_29'><span class='gform-field-label__text'>Achternaam *<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='large'  aria-describedby=\"input_3_29_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_6\" class=\"gfield gfield--type-BirthdayDate_PraktijkdataField gfield--input-type-date gfield--input-type- gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Geboortedatum<\/span><\/legend><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd-mm-yyyy'\n\t\t\t\t\tid='input_3_6'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_6'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99-99-9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_3_6' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_3_6' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_3_6' aria-label='Geboortedatum: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/fieldset><div id=\"field_3_7\" class=\"gfield gfield--type-BSN_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'><span class='gform-field-label__text'>BSN<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='large'  aria-describedby=\"input_3_7_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-StreetName_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'><span class='gform-field-label__text'>Straatnaam<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'  aria-describedby=\"input_3_8_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-HouseNumber_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'><span class='gform-field-label__text'>Huisnummer<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='large'  aria-describedby=\"input_3_9_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-PostalCode_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'><span class='gform-field-label__text'>Postcode<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='large'  aria-describedby=\"input_3_10_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_11\" class=\"gfield gfield--type-City_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'><span class='gform-field-label__text'>Plaats<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='large'  aria-describedby=\"input_3_11_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-PhoneNumber_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_12'><span class='gform-field-label__text'>Telefoonnummer<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_3_12' type='text' value='' class='large'  aria-describedby=\"input_3_12_desc\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-EmailAddress_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_30'><span class='gform-field-label__text'>E-mailadres<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_30' id='input_3_30' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_3\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'><span class='gform-field-label__text'>Klachten\/aanmeldreden<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_3' id='input_3_3' class='textarea medium'   maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'><span class='gform-field-label__text'>Hulpvraag<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_14' id='input_3_14' class='textarea medium'   maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'><span class='gform-field-label__text'>Eventuele eerdere psychologische hulpverlening<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_15' id='input_3_15' class='textarea medium'   maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-LivingSituation_PraktijkdataField gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'><span class='gform-field-label__text'>Leefsituatie<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_3_16' class='large gfield_select'     aria-invalid=\"false\" ><option value='10' selected='selected'>Alleenstaand<\/option><option value='20' >Zonder partner, met kinderen (als ouder in een eenoudergezin)<\/option><option value='30' >Met partner, zonder kinderen<\/option><option value='40' >Met partner, met kinderen<\/option><option value='50' >Als kind in een eenoudergezin<\/option><option value='60' >Als kind in een meeroudergezin<\/option><option value='70' >Niet-ggz-institutie (internaat, gevangenis, asielzoekerscentrum etc.)<\/option><option value='80' >Ggz-institutie<\/option><option value='90' >Zwervend, dakloos<\/option><option value='97' >Anders<\/option><\/select><\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'><span class='gform-field-label__text'>Sociale situatie (werk, opleiding, woonsituatie)<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_17' id='input_3_17' class='textarea medium'   maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'><span class='gform-field-label__text'>Lichamelijke klachten<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_18' id='input_3_18' class='textarea medium'   maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'><span class='gform-field-label__text'>Medicatie<\/span><\/label><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_20' id='input_3_20' class='textarea medium'   maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_21\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_21'><span class='gform-field-label__text'>Intoxicaties<\/span><\/label><div class='gfield_description' id='gfield_description_3_21'>Intoxicaties:\nRook je?\nGebruik je drugs? (zo ja: welke en hoe vaak)\nHoeveel eenheden alcohol drink je per week (gemiddeld)?\nHoeveel koppen koffie drink je per dag?<\/div><div class='ginput_container ginput_container_textarea' data-text-counter-max='600' data-text-counter-template='{current} of {max} max characters'><textarea name='input_21' id='input_3_21' class='textarea medium'  aria-describedby=\"gfield_description_3_21\" maxlength='600'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Client verklaart:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_3_22'>De algemene voorwaarden van de praktijk te hebben gelezen.\n\nWel\/niet akkoord te gaan met het aanleveren van gegevens over de zorgvraagtypering door\nhulpverleners binnen de GGZ (gepseudonimiseerd: niet herleidbaar naar personen) aan de NZa. De\nNZa gebruikt deze informatie voor het onderhouden en doorontwikkelen van het systeem van\nzorgvraagtypering, zodat deze in de toekomst nog beter aansluit op de dagelijkse zorgpraktijk.\n\n\nWel\/niet in te stemmen met uitwisseling van informatie tussen de behandelaar en de\nhuisarts\/verwijzer (zoals het versturen van een afrondende brief aan het einde van de\nbehandeling).\n\nIn te stemmen met uitwisseling van informatie tussen behandelaar en collega\u2019s in intervisievorm\n(geanonimiseerd) en indien nodig tussen behandelaar en de LVVP tijdens de vijfjaarlijkse visitatie in\nhet kader van kwaliteitsbewaking.\n\nAkkoord te gaan met de betalingsvoorwaarden zoals hieronder vermeld. Indien de behandeling\nniet geheel wordt vergoed door de zorgverzekeraar, is cli\u00ebnt bekend met de gemaakte afspraken\nhieromtrent.\n\n\nKosten behandelingen Basis GGZ\nIk hanteer de betalingsvoorwaarden voor vrijgevestigde psychologen (LVVP), zie ook mijn website\nhttps:\/\/estherschuller.com\/?p=291\n\nDe zorg valt onder de Basis GGZ. Binnen de Basis GGZ wordt zorg gedeclareerd volgens het\nZorgprestatiemodel, zie hierover meer op mijn website.\nHoe de vergoeding is geregeld verschilt per zorgverzekeraar. Bekijk altijd uw polisvoorwaarden van uw\nzorgverzekering of neem contact op met uw verzekeraar.\nDe kosten worden na afloop van de behandeling bij uw zorgverzekeraar gedeclareerd door uw\nbehandelaar.\nUw eigen risico wordt aangesproken en indien van toepassing door de zorgverzekeraar bij u in rekening gebracht.\nVoor behandelingen die niet vergoed worden door uw zorgverzekeraar geldt het tarief \u20ac 114,28 euro per 45 minuten directe tijd.\n\nVoor een sessie die niet uiterlijk 24 uur van te voren is afgezegd wordt \u20ac 49,- in rekening gebracht. Deze nota wordt niet door uw verzekeraar vergoed. U kunt deze dus niet indienen bij uw zorgverzekeraar.\n\nPlaats, datum:\n\nNaam cli\u00ebnt: \n\n\nBehandelaar: E. 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