✓ Licensed by Thai Ministry of Health · Residential Rehab #84-03-00294

Creating Your Path to Holina Rehab

Before you arrive at Holina, our clinical team asks you to complete a confidential intake assessment. It is how we get to know you — your history, your health, and your reasons for seeking treatment — so we can configure the best possible treatment plan for you.

Clinically reviewed by Dr. Natalie Lindemann — Clinical Director · Last reviewed 6 July 2026

Complete Your Intake Assessment Speak to Our Team First

Licensed Facility
Reviewed by Our Clinical Team
Individualised Treatment Planning
Koh Phangan, Thailand

Before You Arrive

What Is the Holina Intake Assessment?

The Holina Intake assessment is a confidential questionnaire completed before admission. In order for us to configure the best possible treatment plan for you, we ask that it is completed as honestly as you feel comfortable.

Your responses are reviewed by our clinical team ahead of your arrival at Holina Rehab on Koh Phangan, so that your programme — from medical detox where needed through to primary care and aftercare — is built around your specific history rather than a generic template.

Why We Ask

Every answer feeds directly into the treatment plan our clinical team prepares for you. The more complete the picture we have before you arrive, the more precisely we can plan your care from day one.

Clinical intake review at Holina Rehab Thailand

Holina Rehab — Koh Phangan, Thailand

See our full Clinical Assessment programme →

What We Ask

What the Intake Assessment Covers

The assessment is organised into clear sections so nothing important is missed. You can complete each part at your own pace, and anything you would rather discuss privately can be raised with our clinical team directly.

Personal & Contact Details

Full legal name, date of birth, nationality, passport status, gender, language ability, and current address.

Family & Support Network

Current living arrangement, children or dependents, your relationship with family, and emergency contact details.

Your Reasons for Treatment

Why you are seeking help now, what has triggered this decision, and the three most important things you want to work on at Holina.

Substance Use History

Detailed history by substance — alcohol, cannabis, cocaine/crack, heroin and other opiates, amphetamines/crystal meth, prescribed and non-prescribed medications, benzodiazepines, MDMA, hallucinogens, ketamine, and any others — covering frequency, amount, and duration of use.

Behavioural & Process Addictions

Screening for gambling, gaming, social media/screen use, exercise, shopping, love addiction, sex addiction, overeating, co-dependency, bulimia, anorexia, and OCD, where relevant.

Trauma, Mental Health & Prior Treatment

Unresolved trauma, previous therapy or residential rehab, any mental health diagnoses, and screening around self-harm, suicidal ideation, and criminal or violent history.

Physical Health & Medical History

Current and historic physical health, GP awareness of your situation, mobility, allergies, existing medical records, and any current medication.

Practical Arrangements

Dietary requirements, insurance or travel insurance for your stay, preferred start date and programme length, room type, who is funding treatment, and how you heard about Holina.

Clinical Oversight

Reviewed by Our Clinical Team

Your intake assessment is reviewed by Holina’s clinical team before you arrive, so your treatment plan reflects your history rather than a one-size-fits-all programme.

Dr. Natalie Lindemann

Clinical Director

Doctorate in Forensic Psychology, Alliant International University. Leads the clinical team, overseeing individualised treatment plans and ensuring trauma-informed, evidence-based care across all programmes.

Licensed by the Thai Ministry of Public Health · Residential Rehab Licence #84-03-00294

Ready to Begin?

Complete the confidential intake form below as honestly as you feel comfortable. Anything you would rather not put in writing yet can be discussed privately with our clinical team.

Holina Rehab Intake

Step 1 of 3

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Company

This field is for validation purposes and should be left unchanged.

Personal Information

Please share your personal information

First Name(Required)

First

Last Name(Required)

Last

Date of Birth(Required)

DD slash MM slash YYYY

Phone Number(Required)

Email Address(Required)

Nationality(Required)

Do you have a valid passport?(Required)

Passport Number(Required)

Gender(Required)

Sexual Orientation

What is your current residential address?

Do You Speak English?(Required)

Do You Understand Treatment Is In English?(Required)

Current Living Arrangement?

Do You Have Children or Dependents?

Number of Children or Dependents

Describe Your Current Relationship With Your Family(Required)

Emergency Contact Full Name(Required)

Contact Relationship To You(Required)

Emergency Contact Email(Required)

Emergency Contact Phone Number(Required)

Treatment Desires

In your own words, what is your reason for wanting to come to Holina Rehab?(Required)

Why Do You Want to Come Now? Has Something or Someone Triggered This Choice?(Required)

What Are the 3 Most Important Aspects of Help That You Would Like to Work on Whilst at Holina?(Required)

Substance Addiction

Do you believe you have a problem with substances?

Check the substances you are currently facing challenges with.

None

Alcohol

Cannabis / THC

Cocaine / Crack

Heroin / Opiates (Methadone / Suboxone / Codeines / Fentanyl, Pain Killers, etc)

Amphetamines / Crystal Meth

Benzodiazepines (Valium)

Ketamine

Other Substances

Alcohol Frequency(Required)

Alcohol Most Recent Dose(Required)

Alcohol Amount(Required)

Alcohol Duration of Use in Month / Years(Required)

Cannabis Frequency(Required)

Cannabis Most Recent Dose(Required)

Cannabis Amount(Required)

Cannabis Duration of Use in Month / Years(Required)

Cocaine / Crack Frequency(Required)

Cocaine / Crack Most Recent Dose(Required)

Cocaine / Crack Amount(Required)

Cocaine / Crack Duration of Use in Month / Years(Required)

Heroin Frequency(Required)

Heroin Most Recent Dose(Required)

Heroin Amount(Required)

Heroin Duration of Use in Month / Years(Required)

Amphetamines / Crystal Meth Frequency(Required)

Amphetamines / Crystal Meth Most Recent Dose(Required)

Amphetamines / Crystal Meth Amount(Required)

Amphetamines / Crystal Meth Duration of Use in Month / Years(Required)

Benzodiazepines (Valium) Frequency(Required)

Benzodiazepines (Valium) Most Recent Dose(Required)

Benzodiazepines (Valium) Amount(Required)

Benzodiazepines (Valium) Duration of Use in Month / Years(Required)

Ketamine Frequency(Required)

Ketamine Most Recent Dose(Required)

Ketamine Amount(Required)

Ketamine Duration of Use in Month / Years(Required)

What other substances?

Other Substance Most Recent Dose

Other Substance Frequency

Other Substance Amount

Other Substance Duration of Use in Month / Years

Are there any other prescribed medications you are facing challenges with?(Required)

Do you believe you need a medical detox?(Required)

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.(Required)

Please Give Your Reasons Why If You Answered No or Not Sure(Required)

If You Think You Need Certain Medications, Please Explain Why:

Behavioral Addiction

Check the behaviours you are currently facing challenges with.

Gambling Addiction

Gaming / Social Media / Screen / Internet Addiction

Shopping / Spending / Debting Addiction

Love Addiction

Sex Addiction

Overeating Addiction

Bulimia

Anorexia

Co-dependency / Compulsive Helping Addiction

Obsessive Compulsive Disorder OCD

Other Behavioral Addiction

None

Gambling Addiction Consequences

Gambling Addiciton Length of Issue

Gaming / Social Media / Screen / Internet Addiction Consequences

Gaming / Social Media / Screen / Internet Addiction Length of Issue

Shopping / Spending / Debting Addiction Consequences

Shopping / Spending / Debting Addiction Length of Issue

Love Addiction Consequences

Love Addiction Length of Issue

Sex Addiction Consequences

Sex Addiction Length of Issue

Overeating Consequences

Overeating Length of Issue

Bulimia Consequences

Bulimia Length of Issue

Anorexia Consequences

Anorexia Length of Issue

Co-dependency / Compulsive Helping Addiction Consequences

Co-dependency / Compulsive Helping Addiction Length of Issue

OCD Consequences

OCD Length of Issue

Describe how your OCD manifests itself

Other Behavioral Addiction

Trauma & Emotional Disregulation

Do you believe you have unresolved trauma that will benefit from treatment?(Required)

Please Explain Your History Here

Do you have other Emotional or Behavioural challenges? If so please describe them here.

Therapy History

Have You Been in Therapy Before?(Required)

How Long Were You In Therapy?

What Type of Therapies Have You Engaged With?

Have You Been in Residential Rehabilitation Before?(Required)

Have you been to any Formal Health Program Before?(Required)

Please List the Names of Previous Facilities

Did you complete the full program there?

Please List the Names of Previous Facilities

Mental Health

Have You Ever Received Any Mental Health Diagnosis? (Depression, Anxiety, Bipolar, BPD, Schizophrenia, PTSD, etc)(Required)

Please Give Any Relevant Details

Do You Have Any History of Self-Harm?(Required)

Please describe your self harming

Do You Have Any History of Suicidal Ideations or Suicide Attempts?(Required)

Please Explain and Include a Timeline in the Case of Any Attempts

Would You Like to Share More Details About Your Current Emotional Well-Being?(Required)

Briefly Explain More About Your Emotional Well-Being

Criminal History

Do You Have a Criminal Record or a History of Incarceration?(Required)

Please Describe Your Criminal Behaviour

Do You Have a History of Violent Behaviour?(Required)

Please Describe Your Violent Behaviour

Do You Have any History as a perpetrator of any sexual violence?(Required)

Note: we may be unable to accept you at Holina if you have such a history.

Physical Health

Can You Please Give Us As Much Detail As Possible Concerning Your Current Physical Health? Include Any Current and Historic Problems You May Have:(Required)

Is Your Regular Doctor [GP] Aware of Your Current Situation?

Do You Have Any Medical Records Available to Share With Us (Blood Tests, BMI, Detox History, etc)?

If so please email them to richard.pike@holinakpg.com as early as possible.

Do You Have Any Allergies (Medications, Animals, Stings, etc)?(Required)

Do You Have Any Dietary Requirements, Including Food Allergies?(Required)

Do you need a Kosher or Halal diet?

Additional cost of + $1,200 / mo.

Are You Mobile and Able to Walk Unassisted? [Can you walk up & down stairs?](Required)

Are You Able to Travel to Our Facility Without Assistance?

Name of Prescribing Doctor (GP or Psychiatrist, etc)

Doctor Phone Number

Doctor Email

Are you currently on any prescription medications?(Required)

Why are you taking prescription medications?

List Prescribed Medication #1

Prescribed Reason For Taking

Prescribed Dosage Per Day

List Prescribed Medication #2

Prescribed Reason For Taking

Prescribed Dosage Per Day

List Prescribed Medication #3

Prescribed Reason For Taking

Prescribed Dosage Per Day

List Prescribed Medication #4

Prescribed Reason For Taking

Prescribed Dosage Per Day

List Prescribed Medication #5

Prescribed Reason For Taking

Prescribed Dosage Per Day

Are you currently on any non prescription medications?

List Non Prescribed Medication #1