Complete treatment agreement online │ TinyEYE

Have you been referred by a person or authority?

Yes

No

The name of the person and/or body

Are you the one who needs therapy?

Yes, speech therapy for me

No, I am registering someone else

Contact details

Contact first name

Contact surname

E-mail contact

Contact phone number

Client data (the person receiving speech therapy)

First name client

Last name client

Email

Client phone number

BSN client

If you do not have a BSN enter'999999999'.

Mother tongue client

Address details

House number

Postcode

Street name

City

Current place of residence country client

Gender client

Man

Woman

Please do not answer

Date of birth client

Client age (numbers only)

Insurance data

Health insurer client (if applicable)

Client's insurance number (if applicable) (numbers only)

Do you have a referral?

Referral?

Yes

No

Referred by (name)

Referral date

GP client

Upload your referral letter here

Click to choose a file, or drag and drop a file.

Request for help and availability

In which language should the speech therapy take place?

First preference

Second preference

First day preference

Second preferred daypart

Client request

Consent

Consent for collaboration and data retrieval. For the sake of therapy effectiveness, it is important that the speech therapist collaborates with GPs, teachers and other medical specialists.

Yes

No

Consent for occasional remote monitoring In the context of coaching and training purposes, a session may be monitored remotely on an occasional basis.

Yes

No

Consent to video recording The effectiveness of online therapy is enhanced if the speech therapist can make video recordings of a session where necessary.

Yes

No

I agree to the terms and conditions and privacy policy

Consent and agree to the above

Date agreed

Signature of client

Agreed and declared to have taken note of the terms and conditions:

Fill in the treatment agreement here

This is what we need from you