Application form For whom does the application take place? * Myself Myself and my partner My child and/or my family For a patient of mine Other… Enter other… Geboortedatum kind 1 Geboortedatum kind 2 I am * VUB staff (incl. PhD/post doc) UZ Brussels staff VUB student none of the above Last and first name Required Date of birth Required Street + number Required City Required Telephone number Required E-mail address Required Bij je aangesloten bij een mutualiteit? Yes No What question do you contact BRUCC with? (e.g., counseling, diagnostic assessment, regarding what complaints?) Required Who referred you to BRUCC? Required Make a choiceReferral general practitionerReferral psychiatristReferral UZ Jette/PAIKAReferral study guidance center VUBHuis van Gezondheid - Resilience for healthcare providersNo professional referral Other referral and contact details? If referred by SBC VUB: name student psychologist? General practitioner and contact details? Required What times during the week can you/your client be available? Required Are you open to counseling via teleconsultation or do you prefer face-to-face consultations? * Teleconsult Face-to-face consultation No preference I am in agreement with the privacy policy Required Leave this field blank
