Sample Treatment Agreement Heart Coherence

This form must be signed by both the client and the care provider prior to treatment. One copy is for the client, and the other copy must be kept by the care provider in the client's file.

WGBO

The WGBO (Dutch Healthcare Act) came into effect on April 1, 1995. This law strengthens the client's position vis-à-vis physicians, paramedics, and other care providers. The WGBO regulates, among other things:

the right to information;
the requirement for consent for treatment;
the obligation to maintain a client file;
the client's right to access this file;
the confidentiality of client data.

Wkkgz

Healthcare providers affiliated with the VBAG are bound by the Wkkgz. This law stipulates that healthcare providers must appoint a complaints officer (Quasir) and be affiliated with a government-recognized disputes committee (Zorggeschil). More information can be found at: https://vbag.nl/klachten-en-geschillen/

General Payment Terms

I. These payment terms apply to all treatment agreements between the therapist and the client.

II. Appointments must be cancelled no later than 24 hours before the appointment time. If the appointment is not cancelled in time, the therapist is entitled to charge the client for the reserved time in all fairness and reasonableness.

III. The costs invoiced by the therapist to the client for the treatment must be paid by the client within 30 days of the invoice date.

IV. If the client has not paid the amount due within 30 days of the invoice date, the client is in default without further notice of default being required, and the therapist will charge interest of 1% per month or a portion of the principal amount for as long as the client remains in default.

V. If payment is not made within 30 days of the invoice date, the therapist may send the client a payment reminder. If the client fails to comply with the payment reminder within 14 days, the care provider is entitled to take collection measures or have them carried out by a third party. All costs associated with this claim are borne by the client.

VI. In the event of payment arrears, the care provider is entitled, unless the treatment itself precludes this, to suspend further treatment until the client has fulfilled the payment obligation.

VII. For information about the general terms and conditions, the complaints procedure, and the privacy statement, please refer to our e-mail contact.

Privacy

The client has been informed about the recording of their personal data in the treatment agreement and client file and does consent to this.

The client does consent to the use of their personal data for the purpose of treatment.

*Cross out that which does NOT apply:

Report

The client may/may not * appreciate reports being provided to the GP and/or colleague/referrer during or after treatment.

Personal data retention period:

20 years after the last contact (adults)

Client details:

Last name:
First name:
Initials:
Date of birth:
Address:
Postal code and city:
Telephone:
Email:

What is the nature of your request for help?
If there is a complaint, how long have you had this complaint? Since (date):
Which doctors have you consulted? Please state your name and specialization(s).
If known, what is the diagnosis of your GP/specialist?
What are the recommendations from your GP/specialist?
What have been the results of the treatments you have undergone so far?
Are you currently receiving medical/psychological/psychiatric treatment? Yes/no *
What alternative/additional therapies have you already tried for this complaint(s) besides regular ones?
Other comments/additional information (possibly including attachments):

Date:

Location: Dordrecht

Name of caregiver: Karin Niemann

Client's signature:

Clients aged 12 and over are required to sign. If the client is under 18, the signature of their parent(s) and/or guardian(s) is also required.

Presence during treatment

If the client is a minor, their parents and/or guardian(s) must be present during the treatment.

Signature 1:

Signature 2:

Any adverse consequences resulting from withholding information from the GP in the medical record are the responsibility and expense of the client or their parent(s) and/or guardian(s).