Treatment Agreement Relationship Councelling
The Dutch Medical Treatment Agreement Act (WGBO) contains the legal framework for both clients and therapists. This treatment agreement is based on the WGBO. The WGBO regulates, among other things: the right to information; required consent for minors; the right to access one’s file; and confidentiality of client data.
This treatment agreement has been drawn up in accordance with the guidelines of the European Association for Psychotherapy (EAP).
Therapist Details
therapist's name:
Wilbert Derks
practice address:
St Agnetenweg 23A
postcode:
6545 AS
city:
Nijmegen
AGB code W. Derks:
90047943 / 94017345
AGB code practice:
90056516 / 94060753
Personal Details
surname
first name
middle name / prefix
date of birth
country of birth
the "Personal details" section is required
Address, telephone number and email address
address
postcode
city
telephone number
email address
the "Address, telephone number and email address" section is required
Health insurance
health insurer
policy number
General Practitioner (GP)
referrer
GP’s name
GP’s address
GP’s postcode
GP’s city
GP’s telephone number
What are the complaints? How long have they existed?
What is the client’s request for help?
What is the goal of the therapy, and how will success be measured?
Which doctors or specialists have been consulted?
doctor’s name
doctor’s city
specialist’s name
specialist’s city
If known, what is the diagnosis given by the doctor or specialist?
What instructions or recommendations were given by the doctor or specialist?
What has been the result of previous treatments or therapies (regular or alternative)?
Do you use any medication? If yes, which?
Have you received psychological or psychiatric treatment in the past, or are you currently receiving such treatment? If yes, please state the name of the previous therapist or specialist.
The client acknowledges that withholding information that is present in the medical file of a doctor, specialist or other healthcare provider, while this information is known to the client, may lead to adverse consequences for which the client is personally responsible.
Permissions
The client agrees that information may be obtained in advance from the GP, specialist or colleague therapist.
The client agrees that during or after the treatment, a report may be sent to the GP or referring colleague.
I give the therapist permission to share my email address with the professional association for the client satisfaction survey after therapy.
The survey will be completely anonymous and the emailaddress will only be used for the benefits of the survey. If you want to participate you will receive an email after therapy proposing you to fill in the online survey.
Declarations
I have read the General Payment Terms and agree to them.
I have read the Privacy Statement and agree to it.
checking required
Place and date
city
date
the "Place and date" section is required
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