Register

Register your child for treatment at SAMA now, even if we have not started yet. This way you are assured of a place when we open our doors in the autumn of 2023.

What do you want to sign up for?

Therapy 3 to 12 years

Therapy 7 to 12 years

Parenttraining

Name*

Surname*

Your relationship to client*

Parent/ Guardian

Legal representative

Referrer

Other

Phone number*

Email*

First name client*

Surname client*

Given name client

Date of birth*

Address cliënt*

Zip code

Residence

Do you have a referral from a doctor or general practitioner?*

Yes

No

Is there an indication / decision?

Juvenile law/ Wmo

Wlz

Other

No, there's no indication

Reason for referral / application

I give SAMA Autism Center permission to request data in the interest of the treatment / support. (personal data, medical data, reports from previous institutions / practitioners, consult CIZ data with regard to Wlz indication, consult WMO data.)*

Yes

No

Date*

Signature*

By sending this form I confirm that I have completed everything truthfully and that I have permission to submit the application

Register

SAMA Autisme Centrum

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