{"id":166,"date":"2026-01-23T17:44:22","date_gmt":"2026-01-23T17:44:22","guid":{"rendered":"https:\/\/www.maya-bliss.nl\/?page_id=166"},"modified":"2026-07-18T15:48:52","modified_gmt":"2026-07-18T16:48:52","slug":"intakeformulier","status":"publish","type":"page","link":"https:\/\/www.maya-bliss.nl\/index.php\/intakeformulier\/","title":{"rendered":"Intakeformulier"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Welkom bij Maya &amp; Bliss.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Om iedere behandeling of begeleiding zo goed mogelijk af te stemmen op jouw persoonlijke situatie, vragen wij je dit formulier volledig in te vullen.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">De gegevens worden vertrouwelijk behandeld overeenkomstig onze Privacyverklaring. Uiteraard nemen we voorafgaand aan de behandeling het formulier samen nog even door.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Voordat je het intakeformulier invult, verzoek ik je de pagina <a href=\"https:\/\/www.maya-bliss.nl\/index.php\/info\/\" data-type=\"page\" data-id=\"720\">Voorwaarden &amp; Informatie<\/a> door te nemen:<br><\/p>\n\n\n<style id=\"wpforms-css-vars-135\">\n\t\t\t\t#wpforms-135 {\n\t\t\t\t--wpforms-field-background-color: #ecffdb;\n--wpforms-field-border-color: #376e10;\n--wpforms-field-border-color-spare: #376e10;\n--wpforms-field-text-color: #376e10;\n--wpforms-label-color: #598535;\n--wpforms-label-sublabel-color: #598535;\n--wpforms-button-background-color: #6a9443;\n--wpforms-button-border-color: #0aab02;\n--wpforms-button-text-color: #e9fce8;\n--wpforms-container-padding: 0px;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-radius: 3px;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-135\"><form id=\"wpforms-form-135\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"135\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/166\" data-token=\"3a37e340b126f0833d21c6c16a1f0316\" data-token-time=\"1791285519\"><noscript class=\"wpforms-error-noscript\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-135-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Naam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-135-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" placeholder=\"Voornaam\" aria-errormessage=\"wpforms-135-field_1-error\" required><label for=\"wpforms-135-field_1\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Voornaam<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-135-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" placeholder=\"Achternaam\" aria-errormessage=\"wpforms-135-field_1-last-error\" required><label for=\"wpforms-135-field_1-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Achternaam<\/label><\/div><\/div><\/fieldset><\/div>\t\t<div id=\"wpforms-135-field_3-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"3\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-135-field_3\" >Adres emailadres Let<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-135-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-135-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-135-field_21\" aria-hidden=\"false\">Adres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-135-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" placeholder=\"Adres en huisnummer\" aria-errormessage=\"wpforms-135-field_21-error\" required><\/div><div id=\"wpforms-135-field_23-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">PC + Woonplaats <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-135-field_23\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][23][first]\" placeholder=\"Postcode\" aria-errormessage=\"wpforms-135-field_23-error\" required><label for=\"wpforms-135-field_23\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Voornaam<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-135-field_23-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][23][last]\" placeholder=\"Woonplaats\" aria-errormessage=\"wpforms-135-field_23-last-error\" required><label for=\"wpforms-135-field_23-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Achternaam<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-135-field_2-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"2\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-135-field_2\" aria-hidden=\"false\">Telefoonnummer en\/of emailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-135-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" placeholder=\"Telefoonnummer en\/of emailadres\" spellcheck=\"false\" aria-errormessage=\"wpforms-135-field_2-error\" required><\/div><div id=\"wpforms-135-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-135-field_4\" aria-hidden=\"false\">Geboortedatum<\/label><input type=\"text\" id=\"wpforms-135-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" placeholder=\"Geboortedatum\" aria-errormessage=\"wpforms-135-field_4-error\" ><\/div><div id=\"wpforms-135-field_35-container\" class=\"wpforms-field wpforms-field-textarea wpforms-field-readonly\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-135-field_35\">Welkom<\/label><textarea id=\"wpforms-135-field_35\" class=\"wpforms-field-large\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-135-field_35-error\" >Welkom bij Maya &amp; BlissFijn dat je de tijd neemt om dit formulier in te vullen.Om jou zo goed mogelijk te begeleiden, vraag ik je vooraf enkele vragen te beantwoorden. Zo kan ik de behandeling of coaching zorgvuldig afstemmen op jouw persoonlijke situatie.De informatie die je verstrekt wordt vertrouwelijk behandeld overeenkomstig de Privacyverklaring.Het invullen duurt ongeveer 5 tot 10 minuten.Na het verzenden kun je direct een afspraak plannen.<\/textarea><\/div><div id=\"wpforms-135-field_20-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-135-field_20\">Medische achtergrond <\/label><textarea id=\"wpforms-135-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" placeholder=\"Geef in dit tekstvak aan waar ik rekening mee moet houden bij de behandeling. Mocht je \u00e9\u00e9n van onderstaande aandoeningen hebben, wil je die dan aanvinken?\" aria-errormessage=\"wpforms-135-field_20-error\" ><\/textarea><\/div><div id=\"wpforms-135-field_17-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Meerkeuze<\/legend><ul id=\"wpforms-135-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-135-field_17_1\" name=\"wpforms[fields][17]\" value=\"Ik heb een pacemaker\" aria-errormessage=\"wpforms-135-field_17_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_17_1\">Ik heb een pacemaker<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-135-field_17_2\" name=\"wpforms[fields][17]\" value=\"Epileptische aanvallen\" aria-errormessage=\"wpforms-135-field_17_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_17_2\">Epileptische aanvallen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-135-field_17_3\" name=\"wpforms[fields][17]\" value=\"Hartkwalen\" aria-errormessage=\"wpforms-135-field_17_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_17_3\">Hartkwalen<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-135-field_17_4\" name=\"wpforms[fields][17]\" value=\"Zwangerschap\" aria-errormessage=\"wpforms-135-field_17_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_17_4\">Zwangerschap<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-135-field_17_5\" name=\"wpforms[fields][17]\" value=\"Depressie- of burnoutklachten\" aria-errormessage=\"wpforms-135-field_17_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_17_5\">Depressie- of burnoutklachten<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-135-field_17_6\" name=\"wpforms[fields][17]\" value=\"Overige (svp hieronder toelichten)\" aria-errormessage=\"wpforms-135-field_17_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_17_6\">Overige (svp hieronder toelichten)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-135-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-135-field_19\" aria-hidden=\"false\">Overig<\/label><textarea id=\"wpforms-135-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" placeholder=\"Geef hier eventuele andere bijzonderheden op waar ik rekening mee kan houden.\" aria-errormessage=\"wpforms-135-field_19-error\" ><\/textarea><\/div><div id=\"wpforms-135-field_30-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Verklaringen<\/legend><ul id=\"wpforms-135-field_30\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-135-field_30_1\" name=\"wpforms[fields][30][]\" value=\"Ik verklaar dit formulier naar waarheid te hebben ingevuld.\" aria-errormessage=\"wpforms-135-field_30_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_30_1\">Ik verklaar dit formulier naar waarheid te hebben ingevuld.<\/label><\/li><li class=\"choice-2 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-135-field_30_2\" name=\"wpforms[fields][30][]\" value=\"Ik heb kennisgenomen van de Algemene Voorwaarden.\" aria-errormessage=\"wpforms-135-field_30_2-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_30_2\">Ik heb kennisgenomen van de Algemene Voorwaarden.<\/label><\/li><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-135-field_30_3\" name=\"wpforms[fields][30][]\" value=\"Ik heb kennisgenomen van de Privacyverklaring.\" aria-errormessage=\"wpforms-135-field_30_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_30_3\">Ik heb kennisgenomen van de Privacyverklaring.<\/label><\/li><li class=\"choice-5 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-135-field_30_5\" name=\"wpforms[fields][30][]\" value=\"Ik heb kennisgenomen van het Annuleringsbeleid.\" aria-errormessage=\"wpforms-135-field_30_5-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_30_5\">Ik heb kennisgenomen van het Annuleringsbeleid.<\/label><\/li><li class=\"choice-4 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-135-field_30_4\" name=\"wpforms[fields][30][]\" value=\"Ik geef toestemming voor de verwerking van mijn persoonsgegevens.\" aria-errormessage=\"wpforms-135-field_30_4-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-135-field_30_4\">Ik geef toestemming voor de verwerking van mijn persoonsgegevens.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-135-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-135-field_33\">Let op: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-135-field_33\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][33]\" value=\"Zonder akkoord te gaan met de vijf verklaringen kan geen behandeling plaatsvinden.\" aria-errormessage=\"wpforms-135-field_33-error\" required><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-135-field_3-container { position: absolute !important; overflow: hidden !important; display: 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class=\"wpforms-submit\" data-alt-text=\"Verzenden...\" data-submit-text=\"Verzend\" aria-live=\"assertive\" value=\"wpforms-submit\">Verzend<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.maya-bliss.nl\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Aan het laden\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n\n<p class=\"wp-block-paragraph\">Verzend eerst het intakeformulier en ga daarna door met het maken van de afspraak.<\/p>\n\n\n<!--\nPlugin Name: Bookly - Responsive WordPress Appointment Booking and Scheduling Plugin\nPlugin URI: https:\/\/www.booking-wp-plugin.com\/?utm_source=bookly_admin&utm_medium=plugins_page&utm_campaign=plugins_page\nVersion: 28.4-->\n<style type=\"text\/css\">\n    :root {\n        --bookly-main-color: #878708 !important;\n        --bookly-color: #878708 !important;\n    }\n\n    <\/style><div 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Om iedere behandeling of begeleiding zo goed mogelijk af te stemmen op jouw persoonlijke situatie,&#8230;<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-fullwidth.php","meta":{"_glsr_average":0,"_glsr_ranking":0,"_glsr_reviews":0,"footnotes":""},"class_list":["post-166","page","type-page","status-publish","hentry","post-archive"],"_links":{"self":[{"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/pages\/166","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/comments?post=166"}],"version-history":[{"count":7,"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/pages\/166\/revisions"}],"predecessor-version":[{"id":807,"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/pages\/166\/revisions\/807"}],"wp:attachment":[{"href":"https:\/\/www.maya-bliss.nl\/index.php\/wp-json\/wp\/v2\/media?parent=166"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}