Intakeform

Name, address and situation details

Unique number (ID):*

After you have completed the 'Test your stress' and sent the results to your e-mail address, you have received a unique number from us. You can find this in the relevant e-mail. If you have not sent the results to your e-mail address and therefore do not have a unique number, please fill in the stress test again.

First name and surname:*

Initials:*

Address:*

Postal code:*

City:*

Date of birth:*

Phone number:*

E-mail address:*

Function:*

Contract hours per week:*

Date of sick report:*

Reason for reporting sick:*

Complaints

Medication:

Family/living situation:

Family of origin:

Diagnosis and/or advice from GP/company doctor

Employer/client details

Liberi will not use the below employer/client details and other contact information without your consent. If you wish, you can leave the fields blank and possibly complete them at a later date.

Company name:

Address:

Postal code and city:

Name of contact person:

Function contact person:

Phone number contact person::

E-mail address contact person:

Other contact details

Name of ARBO service:

Company doctor/case manager's name:

Company doctor/ casemanager e-mail address:

Company doctor/ casemanager's phone number:

Appointments

Cancellation of a coaching session must take place at least 24 hours in advance. For cancellations within 24 hours before the start of the session, the costs will be charged to you, unless there are unforeseen circumstances or emergencies (in consultation with and at the discretion of the coach).
We assume that your GP sees no medical objection for you to exercise while coaching in nature (walking/jogging/running). Any injuries or physical limitations should be reported to the coach in advance. Liberi and your assigned coach will not be liable for any injuries or other physical complaints suffered by you during your coaching session due to walking in nature.
All coaches of Liberi must comply with the code of conduct established by Liberi and are also bound by the code of ethics of their professional organisation (NOBCO/ BIG/ SRVB).
All coaches are contractually bound - in accordance with applicable privacy legislation - to maintain confidentiality regarding your personal information as well as that discussed during coaching sessions.
When sharing information with third parties (client/company doctor), we comply with privacy legislation. We explicitly ask for your personal permission for any contact with third parties, whether written or verbal. Reports are only shared with those involved after you have first read them and given your approval.
During the process, we store your (personal) data in a secure environment. In doing so, we comply with privacy legislation and our privacy policy.

Once you have completed the test, a coach will contact you to set up an informal intake.
When there is a click and you want to start a trajectory, we will write a report and make an offer.
Trajectories are often reimbursed by the employer, we can also mediate in this.

By clicking send, you agree to our privacy policy

Schrijf je nu in voor onze maandelijkse nieuwsbrief en blijf op de hoogte van het laatste nieuws over stress en burn-out. Inschrijven

Zoeken

Intakeform

Name, address and situation details

Employer/client details

Other contact details

Appointments

Blijf op de hoogte