Aanmelden - Kick Your Habits

Register

Please fill out the registration form attached at the bottom of this page!

Once we receive that and the referral letter, we will email you our “welcome info” Once you have completed it, you will be placed on our waiting list.

Our good reputation is a great gift, but results in us having a waiting list for individual treatments. It won’t take too long, around 2-6 weeks.

Application form

You can register with us using the secure form below.

Please note that in order to increase the chances of proper treatment in your and our interest, if in doubt we will contact you by phone as a pre-intake. For example, we are not the right place for frequent GHB and opiate use.

Quiting Smoking. The government in its infinite wisdom has decided that smoking cessation will only be reimbursed if performed by the general practitioner/first line. So you can only come to us for this if you also have another addiction. (alcohol?). In other cases we advise you to contact We Quit, they are very good!

First name*
Last name*
Date of birth*
Full address*
Phone*
Email address*
Dutch Social Security Number*
Insurance*
Insurance Policy Number
GP*
Address GP
What are your most important problems and/or complaints? Which substances do you use, how often, and how much?*
For how long have you been experiencing problems with this?*
Do you have an idea about the cause of the problems/complaints? Have you experience events in life that lead to these problems?*
What does a usual day look like for you? Work? Sports? Hobbies?*
What is your living situation? Do you have children? If yes, how old are your children?*
Have you had treatment with a psychologist/psychiatrist before? If yes, when and for what?*
Are there currently any other caregivers involved in your life? If yes, who, in which way, and with which goal?*
Do you use medication? If yes, what?*
What do you think would be the best type of treatment for you? Are you okay with online sessions?*
The letter of referral:*
- Has been sent to us by your GP/psychiatrist/psychologist
- Has been sent to us to info@kickyourhabits.nl
- You still need to request
- You choose to pay the treatment yourself. A letter of referral is not needed.
Location*
Where would you like to follow the treatment?

Once the application form is completed and you’ve received the referral letter from your primary care physician or referring psychiatrist, we will discuss whether we think we are the right place for you. We will contact you within a week after we’ve received both so we can discuss the follow up. You will then be sent a treatment agreement via email. Anyone who fills it out quickly will be referred sooner!
Note: You have to make sure that the referral letter is sent to us.

Important to know: after a successful intake the treatment starts immediately. We match a client with a practitioner, because we think a good connection between you and us is important.