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Application form
For whom does the application take place?
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Myself
Myself and my partner
My child and/or my family
For a patient of mine
Other…
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Date of birth child 1
Date of birth child 2
I am
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VUB staff (incl. PhD/post doc)
UZ Brussels staff
VUB student
none of the above
Last and first name
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Date of birth
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Street + number
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City
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Telephone number
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E-mail address
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Do you have health insurance?
Yes
No
What question do you contact BRUCC with? (e.g., counseling, diagnostic assessment, regarding what complaints?)
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Who referred you to BRUCC?
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Make a choice
Referral general practitioner
Referral psychiatrist
Referral UZ Jette/PAIKA
Referral study guidance center VUB
Huis van Gezondheid - Resilience for healthcare providers
No 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?
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Are you open to counseling via teleconsultation or do you prefer face-to-face consultations?
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Teleconsult
Face-to-face consultation
No preference
I am in agreement with the privacy policy
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