Registration ‘Samen op Zoek’

The form below is for referrers. Are you not a referrer? Click here to go to the registration form for Amsterdam residents.

Sign up

With this form you can register your client for ‘Samen op Zoek’. This conversation is intended as a brief assessment of your client’s mental health. We look at their needs in terms of mental health care, as well as possibilities for support within the social domain. After a telephone appointment, your client will receive advice with suggestions for suitable health care providers they can contact themselves. The appointment is free of charge, and follow-up phone calls are possible if necessary.

Referrer Name *

Position *

Employed at *

Referrer Email Address *

Referrer Phone Number *

Client First Name *

Client Last Name *

Date of birth *

Client Email Address *

Client Phone Number *

Client is insured with

Brief description of help request *

This form asks for your name, phone number, and email address so we can communicate with you. Your information will never be shared with third parties. See our Privacy Statement to learn how we handle your data.