{"id":685,"date":"2024-12-29T10:25:45","date_gmt":"2024-12-29T10:25:45","guid":{"rendered":"https:\/\/hannahelpt.com\/?page_id=685"},"modified":"2026-05-26T13:27:33","modified_gmt":"2026-05-26T13:27:33","slug":"aanmeldvragenlijst-mentalkick","status":"publish","type":"page","link":"https:\/\/hannahelpt.com\/index.php\/aanmeldvragenlijst-mentalkick\/","title":{"rendered":"Aanmeldvragenlijst MentalKick"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"685\" class=\"elementor elementor-685\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d194417 e-flex e-con-boxed e-con e-parent\" data-id=\"d194417\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2bfeb92 elementor-widget elementor-widget-gk_elementor_gravity_form\" data-id=\"2bfeb92\" data-element_type=\"widget\" data-e-type=\"widget\" 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Aanmeldformulier MentalKick<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/index.php\/wp-json\/wp\/v2\/pages\/685' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_96\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Na een telefonische screening zullen wij je vragen om onderstaand formulier in te vullen. Het formulier zal beveiligd verstuurd worden. Met de gegevens kunnen wij een pati\u00ebntdossier aanmaken. Met de voorinformatie kunnen wij ons voorbereiden op het intakegesprek. Heeft er nog geen screening plaatsgevonden, benader ons eerst per mail: contact@hannahelpt.com.<\/p><\/div><div id=\"field_6_126\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>GEGEVENS<\/h2><\/div><div id=\"field_6_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Gegevens jongere<\/h3><\/div><div id=\"field_6_124\" class=\"gfield gfield--type-NamePrefix_PraktijkdataField gfield--input-type-NamePrefix_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_124'>Voorletters *<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_6_124' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_9\" class=\"gfield gfield--type-FirstName_PraktijkdataField gfield--input-type-FirstName_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_9'>Voornaam *<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_6_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_125\" class=\"gfield gfield--type-MiddleName_PraktijkdataField gfield--input-type-MiddleName_PraktijkdataField gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_125'>Tussenvoegsels<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_6_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_12\" class=\"gfield gfield--type-LastName_PraktijkdataField gfield--input-type-LastName_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Achternaam *<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_15\" class=\"gfield gfield--type-BirthdayDate_PraktijkdataField gfield--input-type-date gfield--input-type-datepicker gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_15'>Geboortedatum<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_6_15' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_6_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_15_date_format' class='screen-reader-text'>DD dash MM dash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_15' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_16\" class=\"gfield gfield--type-BSN_PraktijkdataField gfield--input-type-BSN_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_16'>BSN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_6_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-StreetName_PraktijkdataField gfield--input-type-StreetName_PraktijkdataField gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_17'>Straatnaam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_6_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_18\" class=\"gfield gfield--type-HouseNumber_PraktijkdataField gfield--input-type-HouseNumber_PraktijkdataField gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_18'>Huisnummer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_6_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_159\" class=\"gfield gfield--type-HouseNumberSuffix_PraktijkdataField gfield--input-type-HouseNumberSuffix_PraktijkdataField gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_159'>Huisnummer toevoeging<\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_6_159' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_19\" class=\"gfield gfield--type-City_PraktijkdataField gfield--input-type-City_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_19'>Plaats<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-PostalCode_PraktijkdataField gfield--input-type-PostalCode_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>Postcode<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_21\" class=\"gfield gfield--type-MobileNumber_PraktijkdataField gfield--input-type-MobileNumber_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_21'>Mobiel nummer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_6_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_22\" class=\"gfield gfield--type-EmailAddress_PraktijkdataField gfield--input-type-EmailAddress_PraktijkdataField gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_22'>E-mailadres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_6_22' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_6_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Verwijzer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_23'>\n\t\t\t<div class='gchoice gchoice_6_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Huisarts'  id='choice_6_23_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_6_23\"   \/>\n\t\t\t\t\t<label for='choice_6_23_0' id='label_6_23_0' class='gform-field-label gform-field-label--type-inline'>Huisarts<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Centrum Jeugd en Gezin (CJG)'  id='choice_6_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_1' id='label_6_23_1' class='gform-field-label gform-field-label--type-inline'>Centrum Jeugd en Gezin (CJG)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='SPOOR030'  id='choice_6_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_2' id='label_6_23_2' class='gform-field-label gform-field-label--type-inline'>SPOOR030<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Medisch specialist'  id='choice_6_23_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_3' id='label_6_23_3' class='gform-field-label gform-field-label--type-inline'>Medisch specialist<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='gf_other_choice'  id='choice_6_23_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_4' id='label_6_23_4' class='gform-field-label gform-field-label--type-inline'>Anders<\/label><br \/><input id='input_6_23_other' class='gchoice_other_control' name='input_23_other' type='text' value='Anders' aria-label='Andere keuze, gelieve te specificeren'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_6_23'>\n<\/div><\/fieldset><div id=\"field_6_161\" class=\"gfield gfield--type-Document_PraktijkdataField gfield--input-type-Document_PraktijkdataField gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_161'>Voor uploaden verwijzing c.q. rapportage eerdere behandeling<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_161' id='input_6_161' type='file' class='large' aria-describedby=\"gfield_upload_rules_6_161\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_161'>Max. bestandsgrootte: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_161'><\/div> <\/div><\/div><div id=\"field_6_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>GEGEVENS VERWIJZER<\/h2><br>\n<p>U hoeft hieronder enkel de gegevens van de verwijzer in te vullen<\/p><\/div><div id=\"field_6_129\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Gegevens huisarts<\/h3><\/div><div id=\"field_6_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Voornaam en achternaam<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_6_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_28'>Emailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_6_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_30'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_6_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_99\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Zorgverzekering<\/h3><\/div><div id=\"field_6_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_33'>Naam<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_6_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_101\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_101'>Polisnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_6_101' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_102\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Gegevens Centrum Jeugd en Gezin<\/h3><\/div><div id=\"field_6_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_36'>Voornaam en achternaam casemanager<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_6_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_6_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_39'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_6_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_128\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Gegevens Medisch specialist<\/h3><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_38'>Voornaam en achternaam<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_6_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_41'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_6_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_42'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_6_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_139\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>SPOOR030<\/h3><\/div><div id=\"field_6_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_142'>Voornaam en achternaam contactpersoon<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_6_142' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_144'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_6_144' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_147\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_147'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_6_147' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_141\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>School<\/h3><\/div><div id=\"field_6_143\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_143'>Naam school<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_6_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_149\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_149'>Voornaam en achternaam contactpersoon<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_6_149' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_146'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_6_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_148\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_148'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_6_148' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_103\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>GEGEVENS GEZIN<\/h2><\/div><div id=\"field_6_106\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Gegevens ouder<\/h3><\/div><fieldset id=\"field_6_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Jongere leeft in een<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_130'>\n\t\t\t<div class='gchoice gchoice_6_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Compleet gezin'  id='choice_6_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_130_0' id='label_6_130_0' class='gform-field-label gform-field-label--type-inline'>Compleet gezin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Gescheiden gezin'  id='choice_6_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_130_1' id='label_6_130_1' class='gform-field-label gform-field-label--type-inline'>Gescheiden gezin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_130_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Nieuw samengesteld gezin'  id='choice_6_130_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_130_2' id='label_6_130_2' class='gform-field-label gform-field-label--type-inline'>Nieuw samengesteld gezin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_130_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='\u00c9\u00e9n-oudergezin'  id='choice_6_130_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_130_3' id='label_6_130_3' class='gform-field-label gform-field-label--type-inline'>\u00c9\u00e9n-oudergezin<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_130_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Elders'  id='choice_6_130_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_130_4' id='label_6_130_4' class='gform-field-label gform-field-label--type-inline'>Elders<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_44'>Voornaam en achternaam<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_6_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_132\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_132'>Geboorte datum<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_132' id='input_6_132' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/jjjj' aria-describedby=\"input_6_132_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_132_date_format' class='screen-reader-text'>MM slash DD slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_132' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_45'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_6_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_109\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_109'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_6_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_6_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_105\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Gegevens ouder<\/h3><\/div><div id=\"field_6_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_107'>Voornaam en achternaam<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_6_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_133\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_133'>Geboorte datum<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_133' id='input_6_133' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/jjjj' aria-describedby=\"input_6_133_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_133_date_format' class='screen-reader-text'>MM slash DD slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_133' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_108\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_108'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_6_108' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_104\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Indien van toepassing: Gegevens voogd<\/h3><\/div><div id=\"field_6_111\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_111'>Voornaam en achternaam<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_6_111' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_134\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_134'>Geboorte datum<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_134' id='input_6_134' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/jjjj' aria-describedby=\"input_6_134_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_134_date_format' class='screen-reader-text'>MM slash DD slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_134' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_112\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_112'>Telefoonnummer<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_6_112' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_113\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_113'>E-mailadres<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_6_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_115\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Indien de jongere in een gescheiden gezin opgroeit:<\/h3><\/div><div id=\"field_6_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_60'>Naam van gezagdrager(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_6_60' type='text' value='' class='large'    placeholder='Voer N.v.t in als dit niet van toepassing is' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_150\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is er een omgangsregeling?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_150'>\n\t\t\t<div class='gchoice gchoice_6_150_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='Ja'  id='choice_6_150_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_150_0' id='label_6_150_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_150_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='Nee'  id='choice_6_150_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_150_1' id='label_6_150_1' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gaan beide ouders akkoord met een behandeling bij Hanna Psychologie?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_62'>\n\t\t\t<div class='gchoice gchoice_6_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Ja'  id='choice_6_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_0' id='label_6_62_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Nee'  id='choice_6_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_1' id='label_6_62_1' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_117\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Graag invullen als dit van toepassing is<\/h3><\/div><div id=\"field_6_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_67'>Voornaam en achternaam partner<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_6_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_135\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_135'>Geboorte datum<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_135' id='input_6_135' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/jjjj' aria-describedby=\"input_6_135_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_135_date_format' class='screen-reader-text'>MM slash DD slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_135' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_69\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_69'>Naam + geboortejaar van broers \/ zussen<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_69' id='input_6_69' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_137\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_137'>Geboorte datum<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_137' id='input_6_137' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/jjjj' aria-describedby=\"input_6_137_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_137_date_format' class='screen-reader-text'>MM slash DD slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_137' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_70\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_70'>Naam + geboortejaar van stiefouders<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_6_70' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_138\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_138'>Geboorte datum<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_138' id='input_6_138' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/jjjj' aria-describedby=\"input_6_138_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_138_date_format' class='screen-reader-text'>MM slash DD slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_138' class='gform_hidden' value='https:\/\/hannahelpt.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_118\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>PROBLEEMINVENTARISATIE<\/h2><\/div><div id=\"field_6_75\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_75'>1. Wat is je hulpvraag? Wat zijn je klachten?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_6_75' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_77\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_77'>2. Wat verwacht je van de behandeling?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_77' id='input_6_77' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_79\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_79'>3. Heb je eerder hulp gehad of heb je nog hulp? Zo ja: bij wie heb je hulp gezocht?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_6_79' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_78\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_78'>4. Zijn er nare ervaringen van invloed op je angst?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_78' id='input_6_78' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_91\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_91'>5. Hebben anderen in je gezin of familie dezelfde\/andere klachten?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_6_91' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_151\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_151'>6. Zijn er (financi\u00eble of psychische) zorgen binnen het gezin?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_151' id='input_6_151' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_90\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_90'>7. Wat is je eetgewoonte (maaltijden, tussendoortjes, drinken)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_6_90' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_89\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_89'>8. Hoe is je slaappatroon (in slaap komen, doorslapen, opstaan)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_6_89' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_88\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_88'>9. Heb je wel eens lichamelijke klachten (hoofdpijn, buikpijn, misselijk)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_6_88' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_87\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_87'>10. Hoe gaat het op school?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_87' id='input_6_87' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_152\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_152'>11. Heb je vriendschappen? Zo ja, waar heb je je vrienden leren kennen?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_152' id='input_6_152' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_84\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_84'>12. Durf je voor jezelf op te komen als je het ergens niet mee eens bent?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_6_84' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_153\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_153'>13. Welke hobby\u2019s heb je en hoe breng je je vrije tijd meestal door?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_153' id='input_6_153' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_154\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_154'>14. Waar ben je tevreden over?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_154' id='input_6_154' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_155\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_155'>15. Wat verwacht je van de behandeling?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_155' id='input_6_155' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_156\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_156'>16. Wat verwacht u als ouder\/verzorger van de behandeling?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_156' id='input_6_156' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_94\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ik ga hiermee (jonger dan 18? Laat \u00e9\u00e9n van je ouders of voogden tekenen)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_94'>\n\t\t\t<div class='gchoice gchoice_6_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Wel akkoord'  id='choice_6_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_94_0' id='label_6_94_0' class='gform-field-label gform-field-label--type-inline'>Wel akkoord<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Niet akkoord'  id='choice_6_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_94_1' id='label_6_94_1' class='gform-field-label gform-field-label--type-inline'>Niet akkoord<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_121\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Tot slot<\/h2> <br>\n<p>Informatie over de kosten van de behandeling is te vinden op hannahelpt.com. Bij trajecten zonder verwijzer wordt maandelijks een factuur gestuurd. Informeer zelf bij de zorgverzekeraar naar eventuele vergoedingen. Elk jaar wordt er een inflatiecorrectie gedaan op 1 januari.<br><br>\nEen afspraak kan altijd geannuleerd of verzet worden. Stuur hierover een app of mail naar de betreffende behandelaar.; buiten kantooruren alleen per mail. Een afspraak kan kosteloos\ngeannuleerd worden tot 48 uur van tevoren. Wij houden de gereserveerde tijd vrij in\nmijn agenda. Bij afzegging binnen 48 uur v\u00f3\u00f3r de afspraak wordt daarom 50% van\nhet geplande contact in rekening gebracht.<\/p><\/div><fieldset id=\"field_6_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gezien en voor akkoord (jonger dan 18? Laat \u00e9\u00e9n van je ouders of voogden tekenen)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_123'>\n\t\t\t<div class='gchoice gchoice_6_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Wel akkoord'  id='choice_6_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_123_0' id='label_6_123_0' class='gform-field-label gform-field-label--type-inline'>Wel akkoord<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Niet akkoord'  id='choice_6_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_123_1' id='label_6_123_1' class='gform-field-label gform-field-label--type-inline'>Niet akkoord<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_158\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Hanna Psychologie mag met derden anoniem informatie uitwisselen over jouw\nvraagstuk om als zorgverleners met en van elkaar te leren.<\/p><\/div><fieldset id=\"field_6_157\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gezien en voor akkoord (jonger dan 18? Laat \u00e9\u00e9n van je ouders of voogden tekenen)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_157'>\n\t\t\t<div class='gchoice gchoice_6_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Wel akkoord'  id='choice_6_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_157_0' id='label_6_157_0' class='gform-field-label gform-field-label--type-inline'>Wel akkoord<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Niet akkoord'  id='choice_6_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_157_1' id='label_6_157_1' class='gform-field-label gform-field-label--type-inline'>Niet akkoord<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_122\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Door dit formulier te versturen ga je akkoord met het privacyreglement en verklaar je te weten dat Hanna Psychologie Praktijk zich houdt aan de beroepscode en de klachtenregeling. Bovenstaande gegevens worden verwerkt voor het aanmaken van een dossier. Alle persoonsgegevens zijn beveiligd conform de Algemene Verordening Gegevensbescherming (AVG). Het dossier wordt na afsluiting van de behandeling 20 jaar bewaard en wordt nadien automatisch vernietigd.\n<br><br>\nDoor dit formulier te versturen ga je tevens akkoord dat Hanna Psychologie Praktijk niet aansprakelijk is wanneer je kind letsel oploopt tijdens de lichaamsgerichte therapie in de vorm van kickboksen of psychomotorische therapie. Uiteraard zijn de therapeuten waakzaam dat er geen onveilige situaties voorkomen.<br><br>\nBedankt voor het invullen van de vragenlijst en zorgovereenkomst!<\/p><\/div><div id=\"field_6_120\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>BIJ UPLOADEN FORMULIER 10 SECONDEN WACHTEN MET VERSTUREN<\/p><\/div><div id=\"field_6_162\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Zo nodig overleg ik met de verwijzer. Deze informatie-\nuitwisseling is strikt vertrouwelijk en valt onder het medisch beroepsgeheim. 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Het formulier zal beveiligd verstuurd worden. Met de gegevens kunnen wij een pati\u00ebntdossier aanmaken. Met de voorinformatie kunnen wij ons voorbereiden op het intakegesprek. Heeft er nog geen screening plaatsgevonden, benader ons eerst per mail: contact@hannahelpt.com. GEGEVENS Gegevens [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-685","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/pages\/685","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/comments?post=685"}],"version-history":[{"count":7,"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/pages\/685\/revisions"}],"predecessor-version":[{"id":695,"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/pages\/685\/revisions\/695"}],"wp:attachment":[{"href":"https:\/\/hannahelpt.com\/index.php\/wp-json\/wp\/v2\/media?parent=685"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}