{"id":5078,"date":"2026-06-01T20:06:04","date_gmt":"2026-06-01T20:06:04","guid":{"rendered":"https:\/\/pherenike.nl\/aanmelden\/formulier\/"},"modified":"2026-06-01T20:06:04","modified_gmt":"2026-06-01T20:06:04","slug":"formulier","status":"publish","type":"page","link":"https:\/\/pherenike.nl\/en\/aanmelden\/formulier\/","title":{"rendered":"Aanmeldingsformulier"},"content":{"rendered":"<div id=\"ph-aanmeld-wrap\" class=\"ph-aanmeld-wrap\">\n\n  <div class=\"ph-progress\" aria-label=\"Form progress\">\n        <div class=\"ph-progress-step active\" data-step=\"1\">\n      <span class=\"ph-progress-num\">1<\/span>\n      <span class=\"ph-progress-label\">Start<\/span>\n    <\/div>\n        <div class=\"ph-progress-step\" data-step=\"2\">\n      <span class=\"ph-progress-num\">2<\/span>\n      <span class=\"ph-progress-label\">Personal<\/span>\n    <\/div>\n        <div class=\"ph-progress-step\" data-step=\"3\">\n      <span class=\"ph-progress-num\">3<\/span>\n      <span class=\"ph-progress-label\">Municipality<\/span>\n    <\/div>\n        <div class=\"ph-progress-step\" data-step=\"4\">\n      <span class=\"ph-progress-num\">4<\/span>\n      <span class=\"ph-progress-label\">Care<\/span>\n    <\/div>\n        <div class=\"ph-progress-step\" data-step=\"5\">\n      <span class=\"ph-progress-num\">5<\/span>\n      <span class=\"ph-progress-label\">Documents<\/span>\n    <\/div>\n      <\/div>\n\n  <div id=\"ph-aanmeld-success\" class=\"ph-notice ph-notice-success\" style=\"display:none\">\n    <h3>Registration received<\/h3>\n    <p>Thank you for your registration. You will receive a confirmation by email. We will contact you as soon as possible.<\/p>\n  <\/div>\n  <div id=\"ph-aanmeld-error\" class=\"ph-notice ph-notice-error\" style=\"display:none\">\n    <p>An error occurred. Please try again or contact us at <a href=\"mailto:info@pherenike.nl\">info@pherenike.nl<\/a>.<\/p>\n  <\/div>\n\n  <form id=\"ph-aanmeld-form\" novalidate autocomplete=\"off\" action=\"\">\n    <input type=\"hidden\" id=\"ph_nonce\" name=\"ph_nonce\" value=\"4ad5081d15\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/5078\" \/>    <input type=\"hidden\" id=\"ph-token\" name=\"token\" value=\"\">\n\n    <!-- \u2550\u2550\u2550 STAP 1: GESLACHT \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n        <div class=\"ph-step active\" id=\"ph-step-1\">\n      <h2 class=\"ph-step-title\">Step 1 \u2014 Email and gender<\/h2>\n            <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\"><label class=\"ph-label\">Email address <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"email\" name=\"email\" id=\"ph-email\" required autocomplete=\"email\" spellcheck=\"false\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-field\">\n        <fieldset>\n          <legend class=\"ph-label\">What is your gender? <span class=\"ph-req\">*<\/span><\/legend>\n          <label class=\"ph-radio-label\"><input type=\"radio\" name=\"geslacht\" value=\"Man\" required> Male<\/label>\n          <label class=\"ph-radio-label\"><input type=\"radio\" name=\"geslacht\" value=\"Vrouw\"> Female<\/label>\n          <label class=\"ph-radio-label\"><input type=\"radio\" name=\"geslacht\" value=\"Anders\"> Other<\/label>\n        <\/fieldset>\n      <\/div>\n            <div class=\"ph-step-nav\">\n        <button type=\"button\" class=\"ph-btn ph-btn-next\" data-next=\"2\">Next<\/button>\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550 STAP 2: PERSOONLIJK \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"ph-step\" id=\"ph-step-2\">\n      <h2 class=\"ph-step-title\">Stap 2 \u2014 Persoonsgegevens<\/h2>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-5\"><label class=\"ph-label\">First name <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"voornaam\" required autocomplete=\"given-name\"><\/label><\/div>\n        <div class=\"ph-col ph-col-2\"><label class=\"ph-label\">Middle name<input class=\"ph-input\" type=\"text\" name=\"tussenvoegsel\" autocomplete=\"additional-name\"><\/label><\/div>\n        <div class=\"ph-col ph-col-5\"><label class=\"ph-label\">Last name <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"achternaam\" required autocomplete=\"family-name\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Date of birth <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"date\" name=\"geboortedatum\" required autocomplete=\"bday\" min=\"1900-01-01\" max=\"2026-10-23\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Place of birth <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"geboorteplaats\" required autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\">\n          <label class=\"ph-label\">BSN <span class=\"ph-req\">*<\/span> <span class=\"ph-tip\" data-tip=\"Staat op Nederlands paspoort, identiteitskaart of rijbewijs.\">(?)<\/span><input class=\"ph-input\" type=\"text\" name=\"bsn\" id=\"ph-bsn\" required inputmode=\"numeric\" maxlength=\"9\" autocomplete=\"off\" placeholder=\"9 cijfers\"><\/label>\n          <p id=\"ph-bsn-error\" class=\"ph-field-error\" style=\"display:none\">Voer een geldig BSN in (9 cijfers, 11-proef).<\/p>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\">\n          <label class=\"ph-label\">Nationality <span class=\"ph-req\">*<\/span>\n            <select class=\"ph-input\" name=\"nationaliteit\" required>\n              <option value=\"\">\u2014 select \u2014<\/option>\n                            <option>Nederlandse<\/option>\n                            <option>Afghaanse<\/option>\n                            <option>Albanese<\/option>\n                            <option>Algerijnse<\/option>\n                            <option>Amerikaanse<\/option>\n                            <option>Angolese<\/option>\n                            <option>Armeense<\/option>\n                            <option>Australische<\/option>\n                            <option>Azerbeidzjaanse<\/option>\n                            <option>Belgische<\/option>\n                            <option>Boliviaanse<\/option>\n                            <option>Braziliaanse<\/option>\n                            <option>Bulgaarse<\/option>\n                            <option>Chileense<\/option>\n                            <option>Chinese<\/option>\n                            <option>Colombiaanse<\/option>\n                            <option>Deense<\/option>\n                            <option>Duitse<\/option>\n                            <option>Ecuadoriaanse<\/option>\n                            <option>Egyptische<\/option>\n                            <option>Eritrese<\/option>\n                            <option>Estse<\/option>\n                            <option>Ethiopische<\/option>\n                            <option>Filipijnse<\/option>\n                            <option>Finse<\/option>\n                            <option>Franse<\/option>\n                            <option>Georgische<\/option>\n                            <option>Ghanese<\/option>\n                            <option>Griekse<\/option>\n                            <option>Hongaarse<\/option>\n                            <option>Indonesische<\/option>\n                            <option>Iraakse<\/option>\n                            <option>Iraanse<\/option>\n                            <option>Ierse<\/option>\n                            <option>Isra\u00eblische<\/option>\n                            <option>Italiaanse<\/option>\n                            <option>Japanse<\/option>\n                            <option>Jordaanse<\/option>\n                            <option>Kazachstaanse<\/option>\n                            <option>Keniaanse<\/option>\n                            <option>Kosovaarse<\/option>\n                            <option>Kroatische<\/option>\n                            <option>Letse<\/option>\n                            <option>Libanese<\/option>\n                            <option>Litouwse<\/option>\n                            <option>Luxemburgse<\/option>\n                            <option>Marokkaanse<\/option>\n                            <option>Mexicaanse<\/option>\n                            <option>Moldavische<\/option>\n                            <option>Montenegrijnse<\/option>\n                            <option>Nigeriaanse<\/option>\n                            <option>Noorse<\/option>\n                            <option>Oekra\u00efense<\/option>\n                            <option>Oostenrijkse<\/option>\n                            <option>Pakistaanse<\/option>\n                            <option>Poolse<\/option>\n                            <option>Portugese<\/option>\n                            <option>Roemeense<\/option>\n                            <option>Russische<\/option>\n                            <option>Servische<\/option>\n                            <option>Slowaakse<\/option>\n                            <option>Sloweense<\/option>\n                            <option>Soedanese<\/option>\n                            <option>Somalische<\/option>\n                            <option>Spaanse<\/option>\n                            <option>Sri Lankaanse<\/option>\n                            <option>Surinaamse<\/option>\n                            <option>Syrische<\/option>\n                            <option>Tanzaniaanse<\/option>\n                            <option>Thaise<\/option>\n                            <option>Tsjechische<\/option>\n                            <option>Tunesische<\/option>\n                            <option>Turkse<\/option>\n                            <option>Venezolaanse<\/option>\n                            <option>Vietnamese<\/option>\n                            <option>Wit-Russische<\/option>\n                            <option>Zuid-Afrikaanse<\/option>\n                            <option>Zuid-Koreaanse<\/option>\n                            <option>Zweedse<\/option>\n                            <option>Zwitserse<\/option>\n                            <option value=\"Anders\">Other<\/option>\n            <\/select>\n          <\/label>\n        <\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Phone number <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"tel\" name=\"tel\" required autocomplete=\"tel\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-conditional\" id=\"ph-nationaliteit-anders\" style=\"display:none\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Namely <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"nationaliteit_anders\" autocomplete=\"off\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Clean date <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"date\" name=\"cleandatum\" required autocomplete=\"off\" max=\"2026-10-23\"><\/label><\/div>\n      <\/div>\n\n      <h3 class=\"ph-section-title\">Emergency contact #1<\/h3>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\">\n          <label class=\"ph-checkbox-label\">\n            <input type=\"checkbox\" name=\"cp1_ice\" value=\"Ja\">\n            Noodcontact <span class=\"ph-tip\" data-tip=\"&quot;In Case of Emergency&quot; \u2014 de contactpersoon die wordt gebeld in geval van nood.\">(ICE)<\/span>\n          <\/label>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Name <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"cp1_naam\" required autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Relatie tot mij <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"cp1_relatie\" required autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Email address <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"email\" name=\"cp1_email\" required autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Phone number <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"tel\" name=\"cp1_tel\" required autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n\n      <p id=\"ph-ice-error\" class=\"ph-field-error\" style=\"display:none\">Markeer minstens \u00e9\u00e9n contactpersoon als noodcontact (ICE).<\/p>\n      <h3 class=\"ph-section-title\">Emergency contact #2 <span class=\"ph-optional\">(optional)<\/span><\/h3>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\">\n          <label class=\"ph-checkbox-label\">\n            <input type=\"checkbox\" name=\"cp2_ice\" id=\"ph-cp2-ice\" value=\"Ja\">\n            Noodcontact <span class=\"ph-tip\" data-tip=\"&quot;In Case of Emergency&quot; \u2014 de contactpersoon die wordt gebeld in geval van nood.\">(ICE)<\/span>\n          <\/label>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Name<input class=\"ph-input\" type=\"text\" name=\"cp2_naam\" autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Relatie tot mij<input class=\"ph-input\" type=\"text\" name=\"cp2_relatie\" autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Email address<input class=\"ph-input\" type=\"email\" name=\"cp2_email\" autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Phone number<input class=\"ph-input\" type=\"tel\" name=\"cp2_tel\" autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\">\n          <label class=\"ph-label\">Motivatie <span class=\"ph-req\">*<\/span> <span class=\"ph-optional\">\u2014 typ hem hieronder of upload een bestand<\/span>\n            <textarea class=\"ph-input ph-textarea\" name=\"motivatie\" id=\"ph-motivatie\" rows=\"8\" placeholder=\"Vertel ons in ongeveer 200 woorden (minimaal 50) waarom je je aanmeldt en wat je verwacht van ons programma\u2026\"><\/textarea>\n          <\/label>\n          <p class=\"ph-wordcount\">Woorden: <span id=\"ph-motivatie-count\">0<\/span> \u2014 minimaal 50, advies 200<\/p>\n          <div class=\"ph-upload-row ph-upload-row-motivatie\" data-field=\"doc_motivatie\">\n            <label class=\"ph-btn ph-upload-btn\">\n              <input type=\"file\" class=\"ph-file-input\" accept=\".pdf,.docx,.jpg,.jpeg,.png\" data-field=\"doc_motivatie\">\n              Choose file\n            <\/label>\n            <span class=\"ph-upload-status\"><\/span>\n            <span class=\"ph-upload-label\">PDF, Word, JPG of PNG<\/span>\n          <\/div>\n          <input type=\"hidden\" name=\"motivatie_bestand\" id=\"ph-motivatie-bestand\">\n          <p id=\"ph-motivatie-error\" class=\"ph-field-error\" style=\"display:none\">Schrijf minimaal 50 woorden (nu: <span id=\"ph-motivatie-count-err\">0<\/span>) of upload je motivatie als bestand.<\/p>\n        <\/div>\n      <\/div>\n      <div class=\"ph-step-nav\">\n        <button type=\"button\" class=\"ph-btn ph-btn-prev\" data-prev=\"1\">Previous<\/button>\n        <button type=\"button\" class=\"ph-btn ph-btn-next\" data-next=\"3\">Next<\/button>\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550 STAP 3: GEMEENTE & WMO \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"ph-step\" id=\"ph-step-3\">\n      <h2 class=\"ph-step-title\">Stap 3 \u2014 Gemeente en WMO<\/h2>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\"><label class=\"ph-label\">Registered municipality <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"gemeente\" required autocomplete=\"address-level2\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-address-lookup\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-2\"><label class=\"ph-label\">Postcode <span class=\"ph-req\">*<\/span><input class=\"ph-input ph-postcode-input\" type=\"text\" name=\"postcode\" required autocomplete=\"postal-code\" placeholder=\"1234 AB\"><\/label><\/div>\n          <div class=\"ph-col ph-col-2\"><label class=\"ph-label\">Huisnummer <span class=\"ph-req\">*<\/span><input class=\"ph-input ph-huisnummer-input\" type=\"text\" name=\"huisnummer\" required autocomplete=\"off\" placeholder=\"12a\"><\/label><\/div>\n          <div class=\"ph-col ph-col-8 ph-lookup-status-wrap\"><span class=\"ph-lookup-status\"><\/span><\/div>\n        <\/div>\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Adres <span class=\"ph-req\">*<\/span><input class=\"ph-input ph-adres-input\" type=\"text\" name=\"adres\" required autocomplete=\"street-address\"><\/label><\/div>\n          <div class=\"ph-col ph-col-8\"><label class=\"ph-label\">Plaats <span class=\"ph-req\">*<\/span><input class=\"ph-input ph-plaats-input\" type=\"text\" name=\"plaats\" required autocomplete=\"address-level2\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\">\n          <fieldset>\n            <legend class=\"ph-label\">Has a WMO referral been made? <span class=\"ph-req\">*<\/span><\/legend>\n            <label class=\"ph-radio-label\"><input type=\"radio\" name=\"wmo_melding\" value=\"Ja\" required> Yes<\/label>\n            <label class=\"ph-radio-label\"><input type=\"radio\" name=\"wmo_melding\" value=\"Nee\"> No<\/label>\n          <\/fieldset>\n        <\/div>\n      <\/div>\n      <div class=\"ph-conditional\" id=\"ph-wmo-detail\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Municipality WMO referral<input class=\"ph-input\" type=\"text\" name=\"wmo_gemeente\" autocomplete=\"off\"><\/label><\/div>\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">WMO entry date<input class=\"ph-input\" type=\"date\" name=\"wmo_datum\" autocomplete=\"off\" max=\"2026-10-23\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\">\n          <fieldset>\n            <legend class=\"ph-label\">Do you have a contact person at the municipality?<\/legend>\n            <label class=\"ph-radio-label\"><input type=\"radio\" name=\"gemeente_cp\" value=\"Ja\"> Yes<\/label>\n            <label class=\"ph-radio-label\"><input type=\"radio\" name=\"gemeente_cp\" value=\"Nee\"> No<\/label>\n          <\/fieldset>\n        <\/div>\n      <\/div>\n      <div class=\"ph-conditional\" id=\"ph-gemeente-cp-detail\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-12\"><label class=\"ph-label\">Name of municipal contact person<input class=\"ph-input\" type=\"text\" name=\"gemeente_cp_naam\" autocomplete=\"off\"><\/label><\/div>\n        <\/div>\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Email address<input class=\"ph-input\" type=\"email\" name=\"gemeente_cp_email\" autocomplete=\"off\"><\/label><\/div>\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Phone number<input class=\"ph-input\" type=\"tel\" name=\"gemeente_cp_tel\" autocomplete=\"off\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <div class=\"ph-step-nav\">\n        <button type=\"button\" class=\"ph-btn ph-btn-prev\" data-prev=\"2\">Previous<\/button>\n        <button type=\"button\" class=\"ph-btn ph-btn-next\" data-next=\"4\">Next<\/button>\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550 STAP 4: ZORG \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"ph-step\" id=\"ph-step-4\">\n      <h2 class=\"ph-step-title\">Step 4 \u2014 Care<\/h2>\n      <h3 class=\"ph-section-title\">Clinic<\/h3>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Clinic name <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"kliniek_naam\" required autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Discharge date <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"date\" name=\"kliniek_ontslagdatum\" required autocomplete=\"off\" min=\"2026-10-23\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\"><label class=\"ph-label\">Treating clinician name <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"behandelaar_naam\" required autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Treating clinician email <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"email\" name=\"behandelaar_email\" required autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Treating clinician phone<input class=\"ph-input\" type=\"tel\" name=\"behandelaar_tel\" autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\">\n          <label class=\"ph-label\">Soort behandeling <span class=\"ph-req\">*<\/span>\n            <select class=\"ph-input\" name=\"type_behandeling\" required>\n              <option value=\"\">\u2014 select \u2014<\/option>\n              <option>Clinical<\/option>\n              <option>Detox<\/option>\n              <option>Outpatient<\/option>\n              <option>Other<\/option>\n            <\/select>\n          <\/label>\n        <\/div>\n      <\/div>\n      <div class=\"ph-conditional\" id=\"ph-type-anders-detail\" style=\"display:none\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Namely <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"type_behandeling_anders\" autocomplete=\"off\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-12\">\n          <fieldset>\n            <legend class=\"ph-label\">Previously stayed in a safehouse? <span class=\"ph-req\">*<\/span><\/legend>\n            <label class=\"ph-radio-label\"><input type=\"radio\" name=\"eerder_safehouse\" value=\"Ja\" required> Yes<\/label>\n            <label class=\"ph-radio-label\"><input type=\"radio\" name=\"eerder_safehouse\" value=\"Nee\"> No<\/label>\n          <\/fieldset>\n        <\/div>\n      <\/div>\n      <div class=\"ph-conditional\" id=\"ph-safehouse-detail\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-12\"><label class=\"ph-label\">Which safehouse and which location?<input class=\"ph-input\" type=\"text\" name=\"safehouse_locatie\" autocomplete=\"off\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <h3 class=\"ph-section-title\">General Practitioner<\/h3>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Naam huisarts of praktijk <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"huisarts_naam\" required autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Phone number <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"tel\" name=\"huisarts_tel\" required autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-address-lookup\">\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-2\"><label class=\"ph-label\">Postcode<input class=\"ph-input ph-postcode-input\" type=\"text\" name=\"huisarts_postcode\" autocomplete=\"postal-code\" placeholder=\"1234 AB\"><\/label><\/div>\n          <div class=\"ph-col ph-col-2\"><label class=\"ph-label\">Huisnummer<input class=\"ph-input ph-huisnummer-input\" type=\"text\" name=\"huisarts_huisnummer\" autocomplete=\"off\" placeholder=\"12a\"><\/label><\/div>\n          <div class=\"ph-col ph-col-8 ph-lookup-status-wrap\"><span class=\"ph-lookup-status\"><\/span><\/div>\n        <\/div>\n        <div class=\"ph-row\">\n          <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Adres<input class=\"ph-input ph-adres-input\" type=\"text\" name=\"huisarts_adres\" autocomplete=\"street-address\"><\/label><\/div>\n          <div class=\"ph-col ph-col-8\"><label class=\"ph-label\">Plaats<input class=\"ph-input ph-plaats-input\" type=\"text\" name=\"huisarts_plaats\" autocomplete=\"address-level2\"><\/label><\/div>\n        <\/div>\n      <\/div>\n      <h3 class=\"ph-section-title\">Health insurance<\/h3>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Health insurer <span class=\"ph-req\">*<\/span><input class=\"ph-input\" type=\"text\" name=\"verzekeraar\" required autocomplete=\"off\"><\/label><\/div>\n        <div class=\"ph-col ph-col-6\">\n          <label class=\"ph-label\">Soort polis <span class=\"ph-req\">*<\/span>\n            <select class=\"ph-input\" name=\"verzekering_type\" required>\n              <option value=\"\">\u2014 select \u2014<\/option>\n              <option>Basic insurance<\/option>\n              <option>Supplementary<\/option>\n              <option>Other<\/option>\n            <\/select>\n          <\/label>\n        <\/div>\n      <\/div>\n      <div class=\"ph-row\">\n        <div class=\"ph-col ph-col-6\"><label class=\"ph-label\">Polisnummer<input class=\"ph-input\" type=\"text\" name=\"polisnummer\" autocomplete=\"off\"><\/label><\/div>\n      <\/div>\n      <div class=\"ph-step-nav\">\n        <button type=\"button\" class=\"ph-btn ph-btn-prev\" data-prev=\"3\">Previous<\/button>\n        <button type=\"button\" class=\"ph-btn ph-btn-next\" data-next=\"5\">Next<\/button>\n      <\/div>\n    <\/div>\n\n    <!-- \u2550\u2550\u2550 STAP 5: DOCUMENTEN & TOESTEMMING \u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550\u2550 -->\n    <div class=\"ph-step\" id=\"ph-step-5\">\n      <h2 class=\"ph-step-title\">Stap 5 \u2014 Documenten en toestemming<\/h2>\n      <p class=\"ph-step-intro\">Upload the relevant documents (PDF, JPG or PNG, max. 10 MB per file). You can also submit if not all documents are available.<\/p>\n\n            <div class=\"ph-upload-row\" data-field=\"doc_behandelplan\">\n        <span class=\"ph-upload-label\">Treatment plan from clinic<\/span>\n        <label class=\"ph-btn ph-upload-btn\">\n          <input type=\"file\" class=\"ph-file-input\" accept=\".pdf,.docx,.jpg,.jpeg,.png\" data-field=\"doc_behandelplan\">\n          Choose file\n        <\/label>\n        <span class=\"ph-upload-status\"><\/span>\n      <\/div>\n            <div class=\"ph-upload-row\" data-field=\"doc_wmo\">\n        <span class=\"ph-upload-label\">Evidence of WMO referral<\/span>\n        <label class=\"ph-btn ph-upload-btn\">\n          <input type=\"file\" class=\"ph-file-input\" accept=\".pdf,.docx,.jpg,.jpeg,.png\" data-field=\"doc_wmo\">\n          Choose file\n        <\/label>\n        <span class=\"ph-upload-status\"><\/span>\n      <\/div>\n            <div class=\"ph-upload-row ph-upload-row-overig\" data-field=\"doc_overig\">\n        <input class=\"ph-upload-overig-naam\" type=\"text\" name=\"doc_overig_naam\" placeholder=\"Anders, namelijk\u2026\" autocomplete=\"off\">\n        <label class=\"ph-btn ph-upload-btn\">\n          <input type=\"file\" class=\"ph-file-input\" accept=\".pdf,.docx,.jpg,.jpeg,.png\" data-field=\"doc_overig\">\n          Choose file\n        <\/label>\n        <span class=\"ph-upload-status\"><\/span>\n      <\/div>\n\n      <div class=\"ph-avg-block\">\n        <label class=\"ph-checkbox-label\">\n          <input type=\"checkbox\" name=\"avg_consent\" id=\"ph-avg-consent\" required>\n          <span>I give my consent to <strong>Pherenike B.V.<\/strong> 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.<\/span>\n        <\/label>\n      <\/div>\n\n      <div class=\"ph-step-nav\">\n        <button type=\"button\" class=\"ph-btn ph-btn-prev\" data-prev=\"4\">Previous<\/button>\n        <button type=\"submit\" class=\"ph-btn ph-btn-submit\" id=\"ph-submit-btn\">\n          <span class=\"ph-btn-label\">Submit registration<\/span>\n          <span class=\"ph-btn-loading\" style=\"display:none\">Submitting\u2026<\/span>\n        <\/button>\n      <\/div>\n    <\/div>\n\n  <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n<\/div>","protected":false},"excerpt":{"rendered":"1 Start 2 Persoonlijk 3 Gemeente 4 Zorg 5 Documenten Aanmelding ontvangen Bedankt voor je aanmelding. Je ontvangt een bevestiging per e-mail. We nemen zo spoedig mogelijk contact met je op. Er is een fout opgetreden. Probeer het opnieuw of neem contact op via info@pherenike.nl. Stap 1 \u2014 E-mail en geslacht E-mailadres * Wat is [...]","protected":false},"author":0,"featured_media":0,"parent":5071,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-full-width.php","meta":{"footnotes":""},"class_list":["post-5078","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Aanmeldingsformulier - Pherenike<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/pherenike.nl\/en\/aanmelden\/formulier\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Aanmeldingsformulier - Pherenike\" \/>\n<meta property=\"og:url\" content=\"https:\/\/pherenike.nl\/en\/aanmelden\/formulier\/\" \/>\n<meta property=\"og:site_name\" content=\"Pherenike\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/PherenikeGGZ\/\" \/>\n<meta property=\"og:image\" content=\"https:\/\/pherenike.nl\/wp-content\/uploads\/2021\/04\/Logo-Pherenike-klein.png\" \/>\n\t<meta property=\"og:image:width\" content=\"1200\" \/>\n\t<meta property=\"og:image:height\" content=\"396\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:site\" content=\"@pherenike_ggz\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/pherenike.nl\\\/aanmelden\\\/formulier\\\/\",\"url\":\"https:\\\/\\\/pherenike.nl\\\/aanmelden\\\/formulier\\\/\",\"name\":\"Aanmeldingsformulier - Pherenike\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/pherenike.nl\\\/#website\"},\"datePublished\":\"2026-06-01T20:06:04+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/pherenike.nl\\\/aanmelden\\\/formulier\\\/#breadcrumb\"},\"inLanguage\":\"en-GB\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/pherenike.nl\\\/aanmelden\\\/formulier\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/pherenike.nl\\\/aanmelden\\\/formulier\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/pherenike.nl\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Aanmelden\",\"item\":\"https:\\\/\\\/pherenike.nl\\\/aanmelden\\\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Aanmeldingsformulier\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/pherenike.nl\\\/#website\",\"url\":\"https:\\\/\\\/pherenike.nl\\\/\",\"name\":\"Pherenike\",\"description\":\"Voor mensen in herstel\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/pherenike.nl\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-GB\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Aanmeldingsformulier - Pherenike","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/pherenike.nl\/en\/aanmelden\/formulier\/","og_locale":"en_GB","og_type":"article","og_title":"Aanmeldingsformulier - Pherenike","og_url":"https:\/\/pherenike.nl\/en\/aanmelden\/formulier\/","og_site_name":"Pherenike","article_publisher":"https:\/\/www.facebook.com\/PherenikeGGZ\/","og_image":[{"width":1200,"height":396,"url":"https:\/\/pherenike.nl\/wp-content\/uploads\/2021\/04\/Logo-Pherenike-klein.png","type":"image\/png"}],"twitter_card":"summary_large_image","twitter_site":"@pherenike_ggz","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/pherenike.nl\/aanmelden\/formulier\/","url":"https:\/\/pherenike.nl\/aanmelden\/formulier\/","name":"Aanmeldingsformulier - Pherenike","isPartOf":{"@id":"https:\/\/pherenike.nl\/#website"},"datePublished":"2026-06-01T20:06:04+00:00","breadcrumb":{"@id":"https:\/\/pherenike.nl\/aanmelden\/formulier\/#breadcrumb"},"inLanguage":"en-GB","potentialAction":[{"@type":"ReadAction","target":["https:\/\/pherenike.nl\/aanmelden\/formulier\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/pherenike.nl\/aanmelden\/formulier\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/pherenike.nl\/"},{"@type":"ListItem","position":2,"name":"Aanmelden","item":"https:\/\/pherenike.nl\/aanmelden\/"},{"@type":"ListItem","position":3,"name":"Aanmeldingsformulier"}]},{"@type":"WebSite","@id":"https:\/\/pherenike.nl\/#website","url":"https:\/\/pherenike.nl\/","name":"Pherenike","description":"Voor mensen in herstel","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/pherenike.nl\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-GB"}]}},"_links":{"self":[{"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/pages\/5078","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/types\/page"}],"replies":[{"embeddable":true,"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/comments?post=5078"}],"version-history":[{"count":0,"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/pages\/5078\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/pages\/5071"}],"wp:attachment":[{"href":"https:\/\/pherenike.nl\/en\/wp-json\/wp\/v2\/media?parent=5078"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}