lead | DZC

Step 1: Registration form

You fill in the registration form as completely as possible so that we can get an initial idea of your request for help. The entered data will be sent to us securely.

Step 2: Short request

An employee of our registration and information point will contact you within a few days to clarify your request for help and then we will discuss what else is needed to start using the help as quickly as possible. We then get to work matching a coach that best suits your needs.

Step 3: Launch

The coach will contact you, schedule a first appointment with you and then your journey will start!

Do you have doubts after the start whether the coach is a right match? That doesn't matter at all. Then please contact us. Together we will see what a better match would be.

Do you have questions?

Please contact us: call us on 085 – 300 2 300 or e-mail us ai@de-zorgcoach.nl

Registration form

Registration through(Required)

requester himself

Parent/guardian

Referrer

Otherwise

Contact(Required)

requester himself

Parent/guardian

Referrer

Otherwise

Customer data

The details of the person for whom help is requested.

sex(Required)

Man

Woman

Neutral

First name(Required)

Last Name(Required)

BSN(Required)

Date of birth(Required)

Address(Required)

Postal Code(Required)

residence(Required)

Local authority(Required)

phone number(Required)

E-mail address(Required)

Households

Does the requester live with several people?

Yes

Family composition

What members does the customer's family consist of? In other words, other people who do not live in the same household. Enter the name, relationship to the person requesting help (brother, sister, father, mother) and age. Use the plus (+) button to add a line.

Full name

Relationship to requester

Age

If the requester is a minor, who has authority?

Involved (emergency) agencies Use the plus (+) button to add a rule.

Agency name

name contactperson

Function/role

Telephone

E-mail address

Description request for help

What do you need help with?(Required)

What do you think is the cause of the situation(Required)

What do you want to achieve?(Required)

What are you and/or those around you already doing to change the situation?(Required)

Any additions and/or comments

Preferences

We do our utmost to meet your wishes, however it is possible that we cannot fully meet this.

Coach preference(Required)

Man

Woman

No preference

Does the person requesting help speak the Dutch language?(Required)

Yes

Otherwise

pets(Required)

Due to allergies of our coaches, we would like to know if there are pets.

No pets

Dog

Cat

otherwise

Other comments not covered before

Documents

Grant (under 18) and/or municipality decision

NB ! you should always first request the necessary help from the municipality.
This can be done via, for example, a Neighborhood Team, Social Counter, Center for Youth and Family or a Parent and Child Team.
If you already have an award and/or decision, we kindly ask you to upload this letter here.
Uploading this grant letter and/or decision is not mandatory. And can also be sent at a later stage.

Drag files here or

Allowed file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB, Max. number of files: 2.

We would like to know how you found us:

Name received from municipal consultant

Via someone who is already being helped by De Zorgcoach

Municipality website with all providers

I have previously referred to De Zorgcoach

Through a colleague

Via LinkedIn

Referral to another healthcare provider:

Otherwise, namely:

Why choose De Zorgcoach?

The website appeals to me

Someone else recommended De Zorgcoach to me

Usually starts quickly

Deliver good results

Otherwise, namely: