Thank you for your interest in the mental health services of 'Praktijk Lastage'. In order to be able to help you efficiently, you are kindly requested to fill in the pre-intake form and submit it. It is a comprehensive questionnaire which may take between half an hour and an hour to complete. Filling out this form completely leaves more time during the intake to discuss your specific symptoms and health issues and reduced the time spent on the administrative process. In case you are only interested to find out if there is a waiting time or if Praktijk Lastage can offer care that meets your needs, please use the contact form.

Personal information

Name

Gender:

First name:

Initials:

Insertion:

Birth name:

Additional information

Marital status: Not married Married Divorced

Date of birth:

Nationality:

NL national id number:

National id number (non-NL):

Is your married last name the same as your birthname? Yes No

Insertion:

Married last name:

Contact data

Are postal addres and billing addres the same?

Yes

Adressing

Mailing address

Street:

Number:

Postal Code:

City:

Country:

Email:

Phone (landline):

Phone (mobile):

Billing address

Street:

Number:

Postal Code:

City:

Country:

Email:

Your care providers

GP practice name:

GP name:

Street:

Number:

Postal Code:

City:

Phone:

Pharmacy

Pharmacy name:

Phone:

Fax:

Health Insurance

Referral letter

If you have Dutch healthcare insurace, you will need to supply a referral letter to Praktijk Lastage in order to be able to claim a reimbursement of the treatment costs.

Referral letter

I will upload the referral letter now

I will bring it to the intake

I will pay for the treatment myself and won't need a referral letter.

Upload referral letter:

Health insurance company:

Health insurance number:

I was referred by my:

Referred by:

Referrer's practice name:

Referrer's name:

Street:

Number:

Postal Code:

City:

Phone:

We take your privacy very seriously. Please read the privacy section and choose your privacy settings.

Privacy settings

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Als u bezwaar heeft tegen de wettelijk vastgelegde informatieverstrekking van Praktijk Lastage aan uw zorgverzekeraar of het DIS, dan kunt u samen met Praktijk Lastage een privacyverklaring opstellen (zie ook de informatie van de Autoriteit Persoonsgegevens: bron 1, bron2 en de Stichting KDVP). Voor beide soorten gegevensverstrekking bestaan voor en tegenargumenten. Zo is het voorstelbaar dat een ziektekostenverzekeraar graag wil weten welke behandeling vergoedt wordt en draagt anonieme gegevensverwerking door het DIS mogelijk bij aan een hoger niveau geestelijke gezondheidszorg in Nederland. Het is echter aan u om te beslissen of u aan de gegevensverstrekking meewerkt, of dat u een beroep doet op de in de wet verankderde privacyregeling.

My insurace company is allowed to know my diagnosis.

Yes

I want to discuss this during my intake.

I agree that my treatment details are processed anonymously by the 'DBC informatiesysteem' (DIS).

Yes

I want to discuss this during my intake.

Extra questions for anonymous data analysis DIS.

Your birth country:

Birth country of your father:

Birth country of your mother:

Living conditions

Highest education with degree:

You indicated that you don't want your healthcare insurance company to know your diagnosis and/or want to contribute your anonymised treatment details to DIS. For this reason, you will need to sign a privacy statement during the intake. Should you want to claim the treatment cost from your health insurance, you will need to send the signed privacy statement in advance. Note that anonymised NZa rates will be charged for your treatment, otherwise your diagnosis may be deduced from the rate that was charged. Please also understand that the privacy statement may slow down the speed with which your claim is processed by your healthcare insurance. With respect to DIS, Praktijk Lastage will not provide your details.

Background to your help request

Explanation: Try to explain your complaints/problems concisely. There is room for nuance and detail during the intake.

With what would you like help? (2500 chars left)

Why do you ask for help now? (2500 chars left)

What do you expect from Praktijk Lastage? (2500 chars left)

Did you try to find a solution to your symptoms/problem yourself? If so, how

Yes

Explanation: (2500 chars left)

Do you currently receive any form of other treatment? If yes, from whom and what for?

Yes

Explanation: (2500 chars left)

Your mental health history

Have you received treatment from a psychologist or psychiatrist before? If yes, please explain. Yes No

Explanation: (2500 chars left)

Do you register with Praktijk Lastage for the same symptoms/problems for which you received treatment before? Yes No

Did you ever get psychofarmaca prescribed? Yes No

List of psychofarmaca I used earlier:

Did the psychofarmaca have a positive effect on your mental health?

It had a very adverse effect on my mental health

It had an adverse effect on my mental health

It had not a positive nor a negative effect on my mental health

It had a positive effect on my mental health

It had a very positive effect on my mental health

Did you experience side effects from the psychofarmaca? Yes No

Side effects:

Social effects

What influence do your psychological symptoms / problems have in your daily life? (2500 chars left)

Did you tell your partner/children/direct family about your complaints/problems? Yes No

How did your partner/children/direct family respond to your symptoms/problems (2500 chars left)

Did you tell your about your complaints/problems at work/education? Yes No

How did your work/study peers respond to your symptoms/problems? (2500 chars left)

Did you tell about your complaints/problems in other social situations you engage in (leisure time activities)? Yes No

How did your friends/peers respond to your symptoms/problems? (2500 chars left)

With the questions below, we would like to find out more about your family history of mental health and substance abuse. The questions are intended to only touch the surface and the family history be discussed in greater detail during the intake if relevant.

Family history of mental health

Do any of your family members suffer from mental health problems or substance abuse? Yes No

Explanation:

Somatic history

Your health

Basics

What is your height in cm?

What is your weight in kilograms?

Are you currently physically healthy?

Yes

Explanation (2500 chars left)

Did you suffer from severe health problems in the past?

Yes

Explanation: (2500 chars left)

Did you ever suffer from head trauma?

Yes

Explanation: (2500 chars left)

Medication

In view of possible drug interactions, it is important that you report all psychofarmaca and somatic medicines that you currently use. This includes for example the anticonception pill or non-regulated drugs such as supplements which are available from drug stores and pharmacies without a prescription.

Current medication

Do you use any prescription medication?

Yes

Please list the name(s) of the prescribed medication and the amount you use. (2500 chars left)

Did you experience side effects from this medication?

Yes

Side effects: (2500 chars left)

Do you give permission to the psychiatrist to ask your GP for an overview of all medication that is currently prescribed to you?

Yes

Do you use any over the counter medication (i.e. medication without prescription)?

Yes

Please list the name(s) of the over the counter medication and the amount you use. (2500 chars left)

Intoxication

Excessive use of alcohol or cafeine as well as the usage of drugs can negatively affect your mental health. Moreover, there may be interactions with prescription medication. Therefore it is omportant that you specify your substance usage.

Alcohol, cafeine and drugs

How frequently do you drink a glass of alcohol?

Never

Once per month or less

2 - 4 times per month

2 - 3 times per week

4 times per week or more

When you do drink, how many glasses do you drink per occasion?

1 - 2 glasses

3 - 4 glasses

5 - 6 glasses

7 - 9 glasses

10 or more glasses

How frequently do you a cup of coffee?

Never

1 - 2 times per week

3 - 4 times per week

5 - 6 times per week

7 times per week

When you drink coffee, how many cups do you drink per day?

1 - 2 cups

3 - 4 cups

5 - 6 cups

7 - 9 cups

10 or more cups

How frequently do you drink cafeine containing soda (e.g. coke, energy boosters)?

Never

Once per month or less

2 - 4 times per month

2 - 3 times per week

4 times per week or more

When you do drink cafeine containing soda's, how many glasses do you drink per occasion?

1 - 2 glasses

3 - 4 glasses

5 - 6 glasses

7 - 9 glasses

10 or more glasses

Do you smoke tobacco or sigarettes?

Yes

How frequently do you smoke tobacco or sigarettes?

Once per month or less

2 - 4 times per month

2 - 3 times per week

4 times per week or more

When you smoke, how many cigarettes per day?

1 - 2 cigarettes

3 - 4 cigarettes

5 - 6 cigarettes

7 - 9 cigarettes

10 or more cigarettes

Do you use (e.g. party/soft)drugs or substances sold from a so called "smartshop"? If yes, please state the name of the drug and the amount you use per timeunit (i.e. day/week/month).

Yes

Please state the name of the drug and the amount you use per timeunit (i.e. day/week/month). (2500 chars left)

Sign and send

I agree with the terms of payment.

Yes

I have a question about the terms of payment

Your question about the terms of payment:

Thank you for registering with Praktijk Lastage. You will be contacted shortly to further discuss treatment options.

Files submitted, sending form data now. Please do not abort!

Medication

Intoxication

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