{"id":3035,"date":"2026-03-11T08:47:25","date_gmt":"2026-03-11T08:47:25","guid":{"rendered":"https:\/\/mukaddesdilek.nl\/?page_id=3035"},"modified":"2026-03-11T09:08:53","modified_gmt":"2026-03-11T09:08:53","slug":"basvuru-yap","status":"publish","type":"page","link":"https:\/\/mukaddesdilek.nl\/index.php\/basvuru-yap\/","title":{"rendered":"Ba\u015fvuru yap"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--link_color: var(--awb-color7);--awb-border-color:var(--awb-color4);--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:3vw;--awb-padding-bottom:7vw;--awb-margin-bottom:0px;--awb-background-color:var(--awb-color1);--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-stretch fusion-flex-content-wrap\" style=\"max-width:1365px;margin-left: calc(-5% \/ 2 );margin-right: calc(-5% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column fusion-animated\" style=\"--awb-padding-top:4vw;--awb-padding-right:4vw;--awb-padding-bottom:4vw;--awb-padding-left:4vw;--awb-overflow:hidden;--awb-bg-color:var(--awb-color7);--awb-bg-color-hover:var(--awb-color7);--awb-bg-position:center center;--awb-bg-size:cover;--awb-border-radius:6px 6px 6px 6px;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.375%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.375%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:2.375%;--awb-spacing-left-medium:2.375%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:2.375%;--awb-margin-bottom-small:6vw;--awb-spacing-left-small:2.375%;\" data-animationType=\"fadeInUp\" data-animationDuration=\"1.0\" data-animationOffset=\"top-into-view\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"--awb-text-color:var(--awb-color1);--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;\"><h3 class=\"fusion-title-heading title-heading-left\" style=\"margin:0;\">Ba\u015fvuru formu<\/h3><\/div><div class=\"fusion-text fusion-text-1\" style=\"--awb-text-color:var(--awb-color1);\"><p>\u015eu an i\u00e7in T\u00fcrk\u00e7e ba\u015fvuru formumuz bulunmamaktad\u0131r, formumuz sadece Hollandaca dilindedir. Doldurmakta zorluk \u00e7ekerseniz, ileti\u015fim sayfas\u0131 \u00fczerinden bizimle irtibata ge\u00e7mekten l\u00fctfen \u00e7ekinmeyin. Terapi ba\u015fvurusu i\u00e7in a\u015fa\u011f\u0131daki formu doldurman\u0131z\u0131 rica ederiz. Form taraf\u0131m\u0131za ula\u015ft\u0131ktan sonra sizinle ileti\u015fime ge\u00e7ilecektir.<\/p>\n<\/div><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-2919\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-form-label-color:var(--awb-color1);--awb-form-border-color:rgba(226,226,226,0);\" data-form-id=\"2919\" data-config=\"{&quot;form_id&quot;:&quot;2919&quot;,&quot;form_post_id&quot;:&quot;2919&quot;,&quot;post_id&quot;:3035,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:[&quot;message&quot;],&quot;redirect_url&quot;:&quot;&quot;,&quot;redirect_timeout&quot;:&quot;0&quot;,&quot;field_labels&quot;:{&quot;naam&quot;:&quot;Naam&quot;,&quot;geslacht&quot;:&quot;Geslacht&quot;,&quot;adres_huisnummer&quot;:&quot;Adres + huisnummer&quot;,&quot;postcode&quot;:&quot;Postcode&quot;,&quot;plaats&quot;:&quot;Plaats&quot;,&quot;achternaam&quot;:&quot;Achternaam&quot;,&quot;geboortedatum&quot;:&quot;Geboortedatum&quot;,&quot;telefoonnummer&quot;:&quot;Telefoonnummer&quot;,&quot;e-mailadres&quot;:&quot;E-mailadres&quot;,&quot;burgerlijke_staat&quot;:&quot;Burgerlijke staat&quot;,&quot;ik_meld_me_aan_voor&quot;:&quot;Ik meld me aan voor&quot;,&quot;wat_is_de_voornaamste_reden_dat_je_therapie_zoekt&quot;:&quot;Wat is de voornaamste reden dat je therapie zoekt?&quot;,&quot;hoe_lang_heb_je_al_last_van_deze_problemen&quot;:&quot;Hoe lang heb je al last van deze problemen?&quot;,&quot;medische_informatie&quot;:&quot;Medische informatie&quot;,&quot;naam_huisarts&quot;:&quot;Naam huisarts&quot;,&quot;telefoonnummer_huisarts&quot;:&quot;Telefoonnummer huisarts&quot;,&quot;ben_je_onder_behandelinggeweest_van_een_arts_of_therapeut_voor_een_medische_of_psychische_aandoening_zo_ja_graag_toelichten&quot;:&quot;Ben je onder behandeling\\\/geweest van een arts of therapeut voor een medische of psychische aandoening? Zo ja, graag toelichten.&quot;,&quot;gebruik_je_momenteel_medicijnen_zo_ja_welke&quot;:&quot;Gebruik je momenteel medicijnen? Zo ja, welke?&quot;,&quot;zijn_er_medische_aandoeningen_of_medicatie_waarvan_ik_op_de_hoogte_moet_zijn&quot;:&quot;Zijn er medische aandoeningen of medicatie waarvan ik op de hoogte moet zijn?&quot;,&quot;heb_je_eerder_therapie_gehad_zo_ja_welke_vormen_van_therapie_en_wanneer_was_dat&quot;:&quot;Heb je eerder therapie gehad? Zo ja, welke vorm(en) van therapie en wanneer was dat?&quot;,&quot;zijn_er_psychologische_of_psychiatrische_diagnoses_gesteld_in_het_verleden_zo_ja_welke&quot;:&quot;Zijn er psychologische of psychiatrische diagnoses gesteld in het verleden? Zo ja, welke?&quot;,&quot;zijn_er_ingrijpende_levensgebeurtenissen_geweest_die_mogelijk_van_invloed_zijn_op_je_huidige_situatie&quot;:&quot;Zijn er ingrijpende levensgebeurtenissen geweest die mogelijk van invloed zijn op je huidige situatie?&quot;,&quot;welke_symptomen_ervaar_je_momenteel_bijv_angsten_depressie_stress_etc_heb_je_specifieke_doelen_voor_deze_therapie&quot;:&quot;Welke symptomen ervaar je momenteel? (bijv. angsten, depressie, stress, etc.) Heb je specifieke doelen voor deze therapie?&quot;,&quot;is_er_nog_iets_anders_dat_je_wilt_delen_of_waarvan_je_denkt_dat_het_belangrijk_is_voor_de_therapie&quot;:&quot;Is er nog iets anders dat je wilt delen of waarvan je denkt dat het belangrijk is voor de therapie?&quot;,&quot;overige_opmerkingen&quot;:&quot;Overige opmerkingen&quot;},&quot;field_logics&quot;:{&quot;naam&quot;:&quot;&quot;,&quot;geslacht&quot;:&quot;&quot;,&quot;adres_huisnummer&quot;:&quot;&quot;,&quot;postcode&quot;:&quot;&quot;,&quot;plaats&quot;:&quot;&quot;,&quot;achternaam&quot;:&quot;&quot;,&quot;geboortedatum&quot;:&quot;&quot;,&quot;telefoonnummer&quot;:&quot;&quot;,&quot;e-mailadres&quot;:&quot;&quot;,&quot;burgerlijke_staat&quot;:&quot;&quot;,&quot;ik_meld_me_aan_voor&quot;:&quot;&quot;,&quot;wat_is_de_voornaamste_reden_dat_je_therapie_zoekt&quot;:&quot;&quot;,&quot;hoe_lang_heb_je_al_last_van_deze_problemen&quot;:&quot;&quot;,&quot;medische_informatie&quot;:&quot;&quot;,&quot;naam_huisarts&quot;:&quot;&quot;,&quot;telefoonnummer_huisarts&quot;:&quot;&quot;,&quot;ben_je_onder_behandelinggeweest_van_een_arts_of_therapeut_voor_een_medische_of_psychische_aandoening_zo_ja_graag_toelichten&quot;:&quot;&quot;,&quot;gebruik_je_momenteel_medicijnen_zo_ja_welke&quot;:&quot;&quot;,&quot;zijn_er_medische_aandoeningen_of_medicatie_waarvan_ik_op_de_hoogte_moet_zijn&quot;:&quot;&quot;,&quot;heb_je_eerder_therapie_gehad_zo_ja_welke_vormen_van_therapie_en_wanneer_was_dat&quot;:&quot;&quot;,&quot;zijn_er_psychologische_of_psychiatrische_diagnoses_gesteld_in_het_verleden_zo_ja_welke&quot;:&quot;&quot;,&quot;zijn_er_ingrijpende_levensgebeurtenissen_geweest_die_mogelijk_van_invloed_zijn_op_je_huidige_situatie&quot;:&quot;&quot;,&quot;welke_symptomen_ervaar_je_momenteel_bijv_angsten_depressie_stress_etc_heb_je_specifieke_doelen_voor_deze_therapie&quot;:&quot;&quot;,&quot;is_er_nog_iets_anders_dat_je_wilt_delen_of_waarvan_je_denkt_dat_het_belangrijk_is_voor_de_therapie&quot;:&quot;&quot;,&quot;overige_opmerkingen&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;,&quot;submit_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;naam&quot;:&quot;text&quot;,&quot;geslacht&quot;:&quot;select&quot;,&quot;adres_huisnummer&quot;:&quot;text&quot;,&quot;postcode&quot;:&quot;text&quot;,&quot;plaats&quot;:&quot;text&quot;,&quot;achternaam&quot;:&quot;text&quot;,&quot;geboortedatum&quot;:&quot;date&quot;,&quot;telefoonnummer&quot;:&quot;text&quot;,&quot;e-mailadres&quot;:&quot;email&quot;,&quot;burgerlijke_staat&quot;:&quot;select&quot;,&quot;ik_meld_me_aan_voor&quot;:&quot;select&quot;,&quot;wat_is_de_voornaamste_reden_dat_je_therapie_zoekt&quot;:&quot;textarea&quot;,&quot;hoe_lang_heb_je_al_last_van_deze_problemen&quot;:&quot;textarea&quot;,&quot;medische_informatie&quot;:&quot;textarea&quot;,&quot;naam_huisarts&quot;:&quot;text&quot;,&quot;telefoonnummer_huisarts&quot;:&quot;text&quot;,&quot;ben_je_onder_behandelinggeweest_van_een_arts_of_therapeut_voor_een_medische_of_psychische_aandoening_zo_ja_graag_toelichten&quot;:&quot;textarea&quot;,&quot;gebruik_je_momenteel_medicijnen_zo_ja_welke&quot;:&quot;textarea&quot;,&quot;zijn_er_medische_aandoeningen_of_medicatie_waarvan_ik_op_de_hoogte_moet_zijn&quot;:&quot;textarea&quot;,&quot;heb_je_eerder_therapie_gehad_zo_ja_welke_vormen_van_therapie_en_wanneer_was_dat&quot;:&quot;textarea&quot;,&quot;zijn_er_psychologische_of_psychiatrische_diagnoses_gesteld_in_het_verleden_zo_ja_welke&quot;:&quot;textarea&quot;,&quot;zijn_er_ingrijpende_levensgebeurtenissen_geweest_die_mogelijk_van_invloed_zijn_op_je_huidige_situatie&quot;:&quot;textarea&quot;,&quot;welke_symptomen_ervaar_je_momenteel_bijv_angsten_depressie_stress_etc_heb_je_specifieke_doelen_voor_deze_therapie&quot;:&quot;textarea&quot;,&quot;is_er_nog_iets_anders_dat_je_wilt_delen_of_waarvan_je_denkt_dat_het_belangrijk_is_voor_de_therapie&quot;:&quot;textarea&quot;,&quot;overige_opmerkingen&quot;:&quot;textarea&quot;,&quot;notice_1&quot;:&quot;notice&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;,&quot;form_views&quot;:&quot;&quot;,&quot;form_views_counting&quot;:&quot;&quot;}\"><form action=\"https:\/\/mukaddesdilek.nl\/index.php\/basvuru-yap\/\" method=\"post\" class=\"fusion-form fusion-form-2919\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-padding-right:0px;--awb-padding-bottom:0px;--awb-padding-left:0px;--awb-margin-top:0px;--awb-margin-bottom:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:103% !important;max-width:103% !important;margin-left: calc(-3% \/ 2 );margin-right: calc(-3% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-section-separator section-separator slant fusion-section-separator-1\" style=\"--awb-spacer-height:99px;--awb-svg-margin-left:1.455%;--awb-svg-margin-right:1.455%;--awb-svg-margin-left-medium:1.455%;--awb-svg-margin-right-medium:1.455%;--awb-svg-margin-left-small:1.455%;--awb-svg-margin-right-small:1.455%;--awb-divider-height:99px;--awb-spacer-padding-top:inherit;--awb-sep-padding:0;--awb-svg-padding:0;\"><div class=\"fusion-section-separator-svg\"><svg class=\"fusion-slant-candy\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" version=\"1.1\" width=\"100%\" height=\"100\" viewBox=\"0 0 100 100\" preserveAspectRatio=\"none\" fill=\"rgba(242,243,245,1)\"><path d=\"M100 0 L100 100 L0 0 Z\"><\/path><\/svg><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/div><\/div><\/div><div class=\"fusion-text fusion-text-2\" style=\"--awb-text-color:var(--awb-color1);\"><p><strong>Persoonlijke gegevens<\/strong><\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:2.91%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.91%;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:2.91%;--awb-spacing-left-medium:2.91%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"naam\">Naam <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"naam\" id=\"naam\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"geslacht\">Geslacht <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" data-empty-notice=\"Gelieve dit veld in te vullen\" tabindex=\"\" id=\"geslacht\" name=\"geslacht\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"Man\" >Man<\/option><option value=\"Vrouw\" >Vrouw<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"adres_huisnummer\">Adres + huisnummer <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"adres_huisnummer\" id=\"adres_huisnummer\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"postcode\">Postcode <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"postcode\" id=\"postcode\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"plaats\">Plaats <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"plaats\" id=\"plaats\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:2.91%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.91%;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:2.91%;--awb-spacing-left-medium:2.91%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"achternaam\">Achternaam <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"achternaam\" id=\"achternaam\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"geboortedatum\">Geboortedatum <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><input autocomplete=\"off\" type=\"date\" data-empty-notice=\"Gelieve dit veld in te vullen\"  data-first-day=\"1\"  data-format=\"\" tabindex=\"\" id=\"geboortedatum\" name=\"geboortedatum\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\"autocomplete=\"no\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"telefoonnummer\">Telefoonnummer <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"telefoonnummer\" id=\"telefoonnummer\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"e-mailadres\">E-mailadres <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"email\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"e-mailadres\" id=\"e-mailadres\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><\/div><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"burgerlijke_staat\">Burgerlijke staat <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" data-empty-notice=\"Gelieve dit veld in te vullen\" tabindex=\"\" id=\"burgerlijke_staat\" name=\"burgerlijke_staat\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"Gehuwd\" >Gehuwd<\/option><option value=\"Gescheiden\" >Gescheiden<\/option><option value=\"Gescheiden na partnerschap\" >Gescheiden na partnerschap<\/option><option value=\"Gescheiden na wettig huwelijk\" >Gescheiden na wettig huwelijk<\/option><option value=\"Ongehuwd\" >Ongehuwd<\/option><option value=\"Partnerschap\" >Partnerschap<\/option><option value=\"Verweduwd\" >Verweduwd<\/option><option value=\"Verweduwd na partnerschap\" >Verweduwd na partnerschap<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-section-separator section-separator slant fusion-section-separator-2\" style=\"--awb-spacer-height:99px;--awb-svg-margin-left:1.455%;--awb-svg-margin-right:1.455%;--awb-svg-margin-left-medium:1.455%;--awb-svg-margin-right-medium:1.455%;--awb-svg-margin-left-small:1.455%;--awb-svg-margin-right-small:1.455%;--awb-divider-height:99px;--awb-spacer-padding-top:inherit;--awb-sep-padding:0;--awb-svg-padding:0;\"><div class=\"fusion-section-separator-svg\"><svg class=\"fusion-slant-candy\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" version=\"1.1\" width=\"100%\" height=\"100\" viewBox=\"0 0 100 100\" preserveAspectRatio=\"none\" fill=\"rgba(242,243,245,1)\"><path d=\"M100 0 L100 100 L0 0 Z\"><\/path><\/svg><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/div><\/div><\/div><div class=\"fusion-text fusion-text-3\" style=\"--awb-text-color:var(--awb-color1);\"><p><strong>Reden van aanmelding<\/strong><\/p>\n<\/div><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"ik_meld_me_aan_voor\">Ik meld me aan voor <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" data-empty-notice=\"Gelieve dit veld in te vullen\" tabindex=\"\" id=\"ik_meld_me_aan_voor\" name=\"ik_meld_me_aan_voor\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"Brainspotting\" >Brainspotting<\/option><option value=\"Individuele therapie\" >Individuele therapie<\/option><option value=\"Relatietherapie\" >Relatietherapie<\/option><option value=\"Systeemtherapie\" >Systeemtherapie<\/option><option value=\"Gezinstherapie\" >Gezinstherapie<\/option><option value=\"Groepstherapie\" >Groepstherapie<\/option><option value=\"Online therapie\" >Online therapie<\/option><option value=\"Overige\" >Overige<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"wat_is_de_voornaamste_reden_dat_je_therapie_zoekt\">Wat is de voornaamste reden dat je therapie zoekt? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"wat_is_de_voornaamste_reden_dat_je_therapie_zoekt\" name=\"wat_is_de_voornaamste_reden_dat_je_therapie_zoekt\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"hoe_lang_heb_je_al_last_van_deze_problemen\">Hoe lang heb je al last van deze problemen? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"hoe_lang_heb_je_al_last_van_deze_problemen\" name=\"hoe_lang_heb_je_al_last_van_deze_problemen\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"medische_informatie\">Medische informatie<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"medische_informatie\" name=\"medische_informatie\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"naam_huisarts\">Naam huisarts <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"naam_huisarts\" id=\"naam_huisarts\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><div class=\"fusion-form-label-wrapper\"><label for=\"telefoonnummer_huisarts\">Telefoonnummer huisarts <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Gelieve dit veld in te vullen\" name=\"telefoonnummer_huisarts\" id=\"telefoonnummer_huisarts\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"ben_je_onder_behandelinggeweest_van_een_arts_of_therapeut_voor_een_medische_of_psychische_aandoening_zo_ja_graag_toelichten\">Ben je onder behandeling\/geweest van een arts of therapeut voor een medische of psychische aandoening? Zo ja, graag toelichten.<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"ben_je_onder_behandelinggeweest_van_een_arts_of_therapeut_voor_een_medische_of_psychische_aandoening_zo_ja_graag_toelichten\" name=\"ben_je_onder_behandelinggeweest_van_een_arts_of_therapeut_voor_een_medische_of_psychische_aandoening_zo_ja_graag_toelichten\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"gebruik_je_momenteel_medicijnen_zo_ja_welke\">Gebruik je momenteel medicijnen? Zo ja, welke?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"gebruik_je_momenteel_medicijnen_zo_ja_welke\" name=\"gebruik_je_momenteel_medicijnen_zo_ja_welke\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"zijn_er_medische_aandoeningen_of_medicatie_waarvan_ik_op_de_hoogte_moet_zijn\">Zijn er medische aandoeningen of medicatie waarvan ik op de hoogte moet zijn?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"zijn_er_medische_aandoeningen_of_medicatie_waarvan_ik_op_de_hoogte_moet_zijn\" name=\"zijn_er_medische_aandoeningen_of_medicatie_waarvan_ik_op_de_hoogte_moet_zijn\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-section-separator section-separator slant fusion-section-separator-3\" style=\"--awb-spacer-height:99px;--awb-svg-margin-left:1.455%;--awb-svg-margin-right:1.455%;--awb-svg-margin-left-medium:1.455%;--awb-svg-margin-right-medium:1.455%;--awb-svg-margin-left-small:1.455%;--awb-svg-margin-right-small:1.455%;--awb-divider-height:99px;--awb-spacer-padding-top:inherit;--awb-sep-padding:0;--awb-svg-padding:0;\"><div class=\"fusion-section-separator-svg\"><svg class=\"fusion-slant-candy\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" version=\"1.1\" width=\"100%\" height=\"100\" viewBox=\"0 0 100 100\" preserveAspectRatio=\"none\" fill=\"rgba(242,243,245,1)\"><path d=\"M100 0 L100 100 L0 0 Z\"><\/path><\/svg><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/div><\/div><\/div><div class=\"fusion-text fusion-text-4\" style=\"--awb-text-color:var(--awb-color1);\"><p><strong>Psychologische geschiedenis<\/strong><\/p>\n<\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"heb_je_eerder_therapie_gehad_zo_ja_welke_vormen_van_therapie_en_wanneer_was_dat\">Heb je eerder therapie gehad? Zo ja, welke vorm(en) van therapie en wanneer was dat?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"heb_je_eerder_therapie_gehad_zo_ja_welke_vormen_van_therapie_en_wanneer_was_dat\" name=\"heb_je_eerder_therapie_gehad_zo_ja_welke_vormen_van_therapie_en_wanneer_was_dat\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"zijn_er_psychologische_of_psychiatrische_diagnoses_gesteld_in_het_verleden_zo_ja_welke\">Zijn er psychologische of psychiatrische diagnoses gesteld in het verleden? Zo ja, welke?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"zijn_er_psychologische_of_psychiatrische_diagnoses_gesteld_in_het_verleden_zo_ja_welke\" name=\"zijn_er_psychologische_of_psychiatrische_diagnoses_gesteld_in_het_verleden_zo_ja_welke\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-5\" style=\"--awb-text-color:var(--awb-color1);\"><p><strong>Levensgeschiedenis<\/strong><\/p>\n<\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"zijn_er_ingrijpende_levensgebeurtenissen_geweest_die_mogelijk_van_invloed_zijn_op_je_huidige_situatie\">Zijn er ingrijpende levensgebeurtenissen geweest die mogelijk van invloed zijn op je huidige situatie?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"zijn_er_ingrijpende_levensgebeurtenissen_geweest_die_mogelijk_van_invloed_zijn_op_je_huidige_situatie\" name=\"zijn_er_ingrijpende_levensgebeurtenissen_geweest_die_mogelijk_van_invloed_zijn_op_je_huidige_situatie\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-6\" style=\"--awb-text-color:var(--awb-color1);\"><p><strong>Huidige situatie en symptomen<\/strong><\/p>\n<\/div>\n<div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"welke_symptomen_ervaar_je_momenteel_bijv_angsten_depressie_stress_etc_heb_je_specifieke_doelen_voor_deze_therapie\">Welke symptomen ervaar je momenteel? (bijv. angsten, depressie, stress, etc.) Heb je specifieke doelen voor deze therapie?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"welke_symptomen_ervaar_je_momenteel_bijv_angsten_depressie_stress_etc_heb_je_specifieke_doelen_voor_deze_therapie\" name=\"welke_symptomen_ervaar_je_momenteel_bijv_angsten_depressie_stress_etc_heb_je_specifieke_doelen_voor_deze_therapie\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"is_er_nog_iets_anders_dat_je_wilt_delen_of_waarvan_je_denkt_dat_het_belangrijk_is_voor_de_therapie\">Is er nog iets anders dat je wilt delen of waarvan je denkt dat het belangrijk is voor de therapie?<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"is_er_nog_iets_anders_dat_je_wilt_delen_of_waarvan_je_denkt_dat_het_belangrijk_is_voor_de_therapie\" name=\"is_er_nog_iets_anders_dat_je_wilt_delen_of_waarvan_je_denkt_dat_het_belangrijk_is_voor_de_therapie\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above\" style=\"\" data-form-id=\"2919\"><label for=\"overige_opmerkingen\">Overige opmerkingen<\/label><textarea cols=\"40\" autocomplete=\"off\"  minlength=\"0\"  rows=\"2\" tabindex=\"\" id=\"overige_opmerkingen\" name=\"overige_opmerkingen\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.455%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.455%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.455%;--awb-spacing-left-medium:1.455%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--awb-spacing-right-small:1.455%;--awb-spacing-left-small:1.455%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\" data-instance=\"1\"><div class=\"fusion-alert alert success alert-success fusion-alert-left fusion-form-response fusion-form-response-success awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Bedankt voor uw aanvraag. We hebben uw formulier in goede orde ontvangen.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-left fusion-form-response fusion-form-response-error awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Fout bij verzenden. 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