1 Start

2 Personal

3 Municipality

4 Care

5 Documents

Registration received

Thank you for your registration. You will receive a confirmation by email. We will contact you as soon as possible.

An error occurred. Please try again or contact us at info [at] pherenike.nl.

Step 1 — Email and gender

Email address *

What is your gender? * Male Female Other

Stap 2 — Persoonsgegevens

First name *

Middle name

Last name *

Date of birth *

Place of birth *

BSN * (?)

Nationality *

Phone number *

Clean date *

Emergency contact #1

Noodcontact (ICE)

Name *

Relatie tot mij *

Email address *

Phone number *

Emergency contact #2 (optional)

Noodcontact (ICE)

Name

Relatie tot mij

Email address

Phone number

Motivatie * — typ hem hieronder of upload een bestand

Woorden: 0 — minimaal 50, advies 200

Choose file PDF, Word, JPG of PNG

Stap 3 — Gemeente en WMO

Registered municipality *

Postcode *

Huisnummer *

Adres *

Plaats *

Has a WMO referral been made? * Yes No

Municipality WMO referral

WMO entry date

Do you have a contact person at the municipality? Yes No

Name of municipal contact person

Email address

Phone number

Step 4 — Care

Clinic

Clinic name *

Discharge date *

Treating clinician name *

Treating clinician email *

Treating clinician phone

Soort behandeling *

Previously stayed in a safehouse? * Yes No

Which safehouse and which location?

General Practitioner

Naam huisarts of praktijk *

Phone number *

Postcode

Huisnummer

Adres

Plaats

Health insurance

Health insurer *

Soort polis *

Polisnummer

Stap 5 — Documenten en toestemming

Upload the relevant documents (PDF, JPG or PNG, max. 10 MB per file). You can also submit if not all documents are available.

Treatment plan from clinic Choose file

Evidence of WMO referral Choose file

Choose file

I give my consent to Pherenike B.V. to process my personal data in accordance with the GDPR. My data will be used solely for the registration procedure and will not be shared with third parties without my explicit consent. Incomplete registrations are automatically deleted after 14 days.

Registration received

Step 1 — Email and gender

Stap 2 — Persoonsgegevens

Emergency contact #1

Emergency contact #2 (optional)

Stap 3 — Gemeente en WMO

Step 4 — Care

Clinic

General Practitioner

Health insurance

Stap 5 — Documenten en toestemming

Socials

Contact Details

Office Hours

ma-vr

Other Links

Aanmeldingsformulier

Registration received

Step 1 — Email and gender

Stap 2 — Persoonsgegevens

Emergency contact #1

Emergency contact #2 (optional)

Stap 3 — Gemeente en WMO

Step 4 — Care

Clinic

General Practitioner

Health insurance

Stap 5 — Documenten en toestemming

ma-vr