Full Legal Name
Date of Birth
Nationality
Email
Country Code
Phone Number
Do You Have a Valid Passport?
Sexual Orientation
Straight
Gay
LGBTQ+
Other
What Are Your Religious Beliefs?
Current Address
Do You Speak English?
Fluent
Great
Good
Poorly
None
Do You Understand Treatment Is In English?
Current Living Arrangement?
Alone
With Spouse or Partner
With Parents
With Friends
Other
Do You Have Children or Dependents?
Number of Children
Describe Your Current Relationship With Your Family
Emergency Contact Full Name
Contact Relationship To You
Emergency Contact Email
Emergency Contact Country Code
Emergency Contact Phone Number
Reasons For Treatment. In your own words, what is your reason for wanting to come to Holina?
I Have A Substance Addiction (Please Select All that Apply)
Alcohol Frequency
Alcohol Amount
Alcohol Most Recent Dose
Alcohol Duration of Use Months / Years
Cannabis Frequency
Cannabis Amount
Cannabis Duration of Use Months / Years
Cannabis Most Recent Dose
Cocaine Frequency
Cocaine Amount
Cocaine Most Recent Dose
Cocaine Duration of Use Months / Years
Heroin / Opiates (Methadone / Suboxone / Codeines / DF118s / Oxycodone )
Opiate Frequency
Opiate Amount
Opiate Most Recent Dose
Opiate Duration of Use Months / Years
Amphetamines / Crystal Meth
Amphetamines / Crystal Meth Frequency
Amphetamines / Crystal Meth Amount
Amphetamines / Crystal Meth Most Recent Dose
Amphetamines / Crystal Meth Duration of Use Months / Years
Anti- Depressants Frequency
Anti- Depressants Amount
Anti- Depressants Most Recent Dose
Anti- Depressants Duration of Use Months / Years
Solvents & Inhalants / Nitrous Oxide / Laughing Gas
Solvents & Inhalants Frequency
Solvents & Inhalants Amount
Solvents & Inhalants Most Recent Dose
Solvents & Inhalants Duration of Use Months / Years
Benzodiazepine Frequency
Benzodiazepine Amount
Benzodiazepine Most Recent Dose
Benzodiazepine Duration of Use Months / Years
Prescribed Mood-Altering Medications
Medication Frequency
Medication Amount
Medication Most Recent Dose
Medication Duration of Use Months / Years
MDMA / Ecstasy Frequency
MDMA / Ecstasy Amount
MDMA / Ecstasy Most Recent Dose
MDMA / Ecstasy Duration of Use Months / Years
Hallucinogens (LSD, Mushrooms, etc)
Hallucinogen Frequency
Hallucinogen Amount
Hallucinogen Most Recent Dose
Hallucinogen Duration of Use Months / Years
Ketamine Frequency
Ketamine Amount
Ketamine Most Recent Dose
Ketamine Duration of Use Months / Years
Other Substances Frequency
Other Substances Amount
Other Substances Most Recent Dose
Other Substances Duration of Use Months / Years
Do You Think You Need A Medical Detox?
Are you ready and willing to move towards abstinence from all substances? NOTE: Treatment may be refused if you are not interested in moving towards abstinence.
Please Give Your Reasons Why If You Answered No or Not Sure
If You Think You Need Certain Medications, Please Explain Why:
I Have A Behavioural Addiction
Sex Addiction Consequences
Sex Addiction Length of Issue
Gambling / Risk Taking Consequences
Gambling / Risk Taking Length of Issue
Exercise Consequences
Exercise Length of Issue
Shopping / Spending / Debting
Shopping / Spending / Debting Consequences
Shopping / Spending / Debting Length of Issue
Love Addiction Consequences
Love Addiction Length of Issue
Gaming Consequences
Gaming Length of Issue
Overeating Consequences
Overeating Length of Issue
Co-dependency / Compulsive Helping
Co-dependency / Compulsive Helping Consequences
Co-dependency / Compulsive Helping Length of Issue
Social Media / Screen Addiction
Internet / Social Media Consequences
Internet / Social Media Length of Issue
Bulimia / Anorexia Consequences
Bulimia / Anorexia Length of Issue
Other Behavioural Addiction
Do You Believe You Have Unresolved Trauma That Will Benefit From Treatment?
If Yes: Please Explain Your History Here
Can You Specifically Identify the Traumatic Events in Your Life as Physical, Emotional, Sexual, or Domestic Violence?
If Yes: Please Explain
Have You Been in Treatment Before?
If Yes: How Long Were You In Treatment?
If Yes: Please List the Names of Previous Facilities & Time Spent at Each
Have You Ever Received Any Mental Health Diagnosis? (Depression, Anxiety, Bipolar, BPD, PTSD, etc)
If Yes: Please Give Any Relevant Details
Do You Have Any History of Self-Harm?
If Yes: Please Explain
Do You Have Any History of Suicidal Ideations or Suicide Attempts?
If Yes: Please Explain
Do You Have a Criminal Record or a History of Incarceration?
If Yes: Please Describe Your Criminal Behaviour
Do You Have a History of Violent Behaviour?
If Yes: Please Describe Your Violent Behaviour
Would You Like to Share More Details About Your Current Emotional Well-Being?
If Yes: Briefly Explain More About Your Emotional Well-Being
Can You Please Give Us As Much Detail As Possible Concerning Your Current Physical Health? Include Any Current and Historic Problems You May Have:
Is Your Regular Doctor [GP] Aware of Your Current Situation?
Are You Mobile and Able to Walk Unassisted?
Do You Have Any Allergies (Medications, Animals, Stings, Foods, etc)?
Do You Have Any Medical Records Available to Share With Us (Blood Tests, BMI, Detox History, etc)?
Name of Prescribing Doctor (GP or Psychiatrist, etc)
Doctor Email
Doctor Country Code
Doctor Phone Number
List Any Current Prescribed Medication
Prescribed Dosage & Frequency
Prescribed Reason For Taking
List Any Current Non-Prescribed Medication
Are You Able to Travel to Our Facility Without Assistance?
If No: Please Provide the Details of Assistance Needed
Do You Have Any Dietary Requirements, Including Food Allergies?
We Require All Residents to Have Medical Insurance or Travel Insurance for the Duration of Their Stay. Can You Source This? (Make sure your insurance can be extended remotely should you remain in Thailand longer than anticipated)
Yes
No
Unsure At This Time
When Do You Want to Come to Treatment?
How Long Would You Like to Come to Treatment?
4 Weeks
6 Weeks
8 Weeks
12 Weeks
16 Weeks
18 Weeks
24 Weeks
Please Choose Your Room Type- All Prices + 7% Sales Tax
Shared Room with Seaview $7,500 per month
Single Occupancy Seaview & Sunset facing Bungalow $10,000 per month
Private Pool Villa $12,000 per month
Pool Side Suite with Seaview $15,000 per month
Beach Bungalow with Seaview and Sunset facing $15,000 per month
Person Funding Treatment
Me
Family Member
Friend
A Sponsor
Please Choose Your Method Of Payment (Our Wise Transfer Email is info@holinawellness.com)
International Bank Transfer (Best & Preferred Option)
Wise Transfer
Credit / Debit Card Payment (Available on Arrival With 3.5% Surcharge
Other
How Did You First Hear About Holina?
Facebook
Instagram
Google
Online Advertisement
Holina Website
Recommendation
Luxury Rehabs
Other
Please Type Your Full Name To Confirm The Assessment Then Press Submit
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