Aanmeldingsformulier

Aanmeldingsformulier Garcia Huis:
Persoonlijke gegevens:
Voornamen:…………..…..……………………………………………………………………………
Achternaam: 0 Dhr. 0 Mw …………………...……………………………………………………….
Geboortedatum: …….………....................................................................................................
Geboorteplaats: ........................................................................................................................
BSN: ………………………………………...………………………………………………………….
Nationaliteit: ..............................................................................................................................
Burgerlijke staat: ........................................................................................................................
Aantal Kinderen: ........................................................................................................................
E-mail adres ……………………………………………………………………………………………
Nederlands sprekend: 0 ja 0 nee
Woongegevens cliënt:
Adres:........................................................................................................................................
Postcode / Woonplaats: ...........................................................................................................
Telefoon: ..................................................................................................................................
Wat is de aanleiding voor aanmelding van de cliënt?
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Datum aanmelding:...................................................................................................................
Contactpersoon ( familie, sociaal netwerk ):
Achternaam: . 0 Dhr. 0 Mw. ………………………………………………………………………….
Voorletter(s): .............................................................................................................................
Adres: .......................................................................................................................................
Postcode / Woonplaats: ............................................................................................................
Relatie tot cliënt: .......................................................................................................................
Telefoon: ...................................................................................................................................
Gegevens zorgverzekering:
Naam zorgverzekeraar: ............................................................................................................
Adres: ........................................................................................................................................
Postcode / Woonplaats: .............................................................................................................
Polisnummer: .............................................................................................................................
Huisarts Naam: 0 Dhr. 0Mw. ......................................................................................................
Adres: .........................................................................................................................................
Postcode - plaats: ......................................................................................................................
Telefoon: ....................................................................................................................................
Apotheek: …………………………………………………………….…………………………………
Adres en telefoon: ………………………………………………………………...……………………
Tandarts: ……………………………………………………………..…………………………………
Adres en telefoon: ……………………………………………………………….…………………….
Medisch-psychiatrische gegevens: Diagnose volgens DSM IV
As I .............................................................................................................................................
As II ............................................................................................................................................
As III (somatiek) .........................................................................................................................
As IV ..........................................................................................................................................
AS V ..........................................................................................................................................
Medicatielijst:
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Wilt u meer informatie over specifieke woonvormen neemt u dan contact op met het Garcia
huis.
Cliënt Verwijzer Datum ___________________________
Datum ________________________
Plaats ________________________
Handtekening cliënt
_________________________________________________________
Handtekening verwijzer
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* Wanneer het formulier is opgestuurd krijgt u van ons zo spoedig mogelijk mail van een
uitnodiging voor een officieel aanmeldingsgesprek. In de mail staat meer informatie over het
aanmeldingsgesprek. Heeft u nog vragen kunt u ons altijd mailen.
Mail: [email protected]