Intake Form - Praktijk Vrije Geest

Theralogio

Intake Form - Complete all steps to begin your therapy journey

Progress

1Personal Info 2Address & ID 3Medical Info 4Preferences 5Review

Need help?

If you have questions about the intake form, please contact us.

Personal Information

Please provide your basic contact information.

First Name *

Last Name *

Email Address *

Phone Number *

Belgian format: +32xxxxxxxxx or 0xxxxxxxxx

Date of Birth *

You must be at least 18 years old

Sex *

Your data is protected under GDPR and Belgian healthcare regulations.
Medical records are retained for 30 years as required by law.