BMHC Patient Admission Form

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Colleagues or groups who can often welcome you within 14 days
⚠️ No psychiatrists available at the moment
⏳ WAITING LIST

Select caregiver to be put on their waiting list
Lina Butkute, PhD · Individual Psychotherapy / EMDR / Couples Therapy · 🇬🇧 🇷🇺 🇱🇹

Christopher Grogan, PhD · Clinical Psychologist · 🇬🇧

Marjolein Stevens · Individual Psychotherapy · MBT · 🇳🇱 🇬🇧

Dr. Thomas Van der Poorten · Psychiatrist · 🇳🇱 🇫🇷 🇬🇧

Eric Lambrechts · Individual Psychotherapy (uniquement français)
If a caregiver does not appear in the form currently,
it means they are unavailable. Feel free to check back later.

Reason of consultation
Name
Referred by
Email
Phone Number

Country CodePhone Number
Your privacy is essential to us. The information you provide is handled in strict confidence and used only for your care, in accordance with our privacy policy.

Date of Birth
Home Address

Street Address, City & Postal Code

City, Postal Code

Postal / Zip Code
How did you find out about us?
Terms & Conditions
⚠️ Please use this form responsibly by applying to one caregiver at a time and noting that medication requests cannot be accommodated at this time. In need of a psychiatrist? Call +3223186057 for referral advice.
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