Digitaal verwijzen

Name*

Address*

Postal code*

City*

Date of birth*

Phone number

Name*

Address 1

Address 2

Postal code

City*

Phone number

E-mail

Complaint

Medical history

Differential diagnosis / Diagnosis

Has there been consultation/diagnostics/treatment elsewhere for this? Yes No

If yes, where?

What were the findings?

Was the case discussed with a practitioner at Kempenhaeghe? No Yes

If yes, with whom?

Does the patient have an intellectual disability? Yes No

Persistent insomnia following complete cognitive behavioral therapy for insomnia

Where did CGT-i take place:

Insomnia and comorbid sleeping disorder

What sleep diagnosis was made:

Insomnia within the framework of another medical disorder, where maximal treatment of the medical disorder did not reduce the insomnia complaints.

Which medical comorbidity is involved:

Insomnia and comorbid serious psychiatry => Patient is referred back following diagnosis when there is no organic sleep pathology.

Which psychiatric diagnoses have been established: Where does current treatment take place:

Primary insomnia => patient will be referred back.

(for acceptancy policy see previously on this page)

Note: Please send attachments, such as results of previous diagnostic examinations and correspondence, listing the patient’s information, to:

Kempenhaeghe
attn. secretariaat polikliniek Center for Sleep Medicine
Postbus 61
5590 AB Heeze

Or:

Kempenhaeghe
attn. secretariaat polikliniek Center for Sleep Medicine
Postbus 250
4900 AG OOSTERHOUT