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Addiction Treatment Center

12 Step Holistic Resort

Holina Assessment Aug 2023

Holina Assessment

In order for us to configure the best possible treatment plan for you, please
complete this form as honestly as you feel comfortable. If there are parts you’d
rather not write at this time, then these can be discussed privately either by video
call or once you’re under our care.

1: Personal INFORMATION
Please Fill In Your Details Below
Full Name *
Nationality
Contact Number
Country Code
Current Address
What are your Religious Beliefs?
Date Of Birth
day / month / year
Email Address *
Do you have a valid Passport?
Gender
How Do You Identify?
Do You Speak English?
Do you understand that treatment is delivered in English?
Current Living Arrangement
please explain your current living arrangement *
2: Family & Marital Status
Do You Have Children or Dependents:
Number Of Children
Describe Your Current Relationship With Your Family
Sexual Orientation
Other Details
3: Emergency Contact
Please Provide Details Below
Emergency Contact Full Name
Emergency Contact E-Mail
Emergency Contact Phone
Contact Relationship To You
Emergency Contact Country Code
4: Reasons For Treatment
Please Fill In Your Details Below
In your own words, what is your reason for wanting to come to Holina at this time?
5: Substance Addiction Questionnaire
Substances being used currently and historically, including Alcohol and Prescription Medication - Please click what applies to you if you choose yes
I Have A Substance Addiction *
Please click what applies to you
Alcohol *
Alcohol Frequency
Alcohol Amount
Alcohol Most Recent Dose
Alcohol duration of use Months / Years
Cocaine (powder) *
Cocaine (powder) Frequency
Cocaine (powder) Amount
Cocaine (powder) Most Recent Dose
Cocaine (powder) duration of use Months / Years
Other Opiates (Methadone / Suboxone / Codeines / DF118s / Oxycodone )
Other Opiates (Methadone / Suboxone / Codeines / DF118s / Oxycodone ) Frequency
Other Opiates (Methadone / Suboxone / Codeines / DF118s / Oxycodone ) Amount
Other Opiates (Methadone / Suboxone / Codeines / DF118s / Oxycodone ) Most Recent Dose
Other Opiates (Methadone / Suboxone / Codeines / DF118s / Oxycodone ) duration of use Months / Years
Anti- Depressants *
Anti- Depressants Frequency
Anti-Depressants Amount
Anti- Depressants Most Recent Dose
Anti- Depressants duration of use Months / Years
Ketamine
Ketamine Frequency
Ketamine Amount
Ketamine Most Recent Dose
Ketamine duration of use Months / Years
Others
Other 1 Frequency
Other 1 Amount
Other 1 Most Recent Dose
Other 1 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
Crack *
Crack Frequency
Crack Amount
Crack Most Recent Dose
Crack duration of use: Months / Years
Codeines / DF118s / Oxycodone
Codeines / DF118s / Oxycodone Frequency
Codeines / DF118s / Oxycodone Amount
Codeines / DF118s / Oxycodone Most Recent Dose
Codeines / DF118s / Oxycodone duration of use Months / Years
Solvents & Inhalants (Including nitrous oxide)
Solvents & Inhalants Frequency
Solvents & Inhalants Amount
Solvents & Inhalants Most Recent Dose
Solvents & Inhalants duration of use Months / Years
MDMA / Ecstasy
MDMA / Ecstasy Frequency
MDMA / Ecstasy Amount
MDMA / Ecstasy Most Recent Dose
MDMA / Ecstasy duration of use Months / Years
Benzodiazepines (Valium)
Benzodiazepines (Valium) Frequency
Benzodiazepines (Valium) Amount
Benzodiazepines (Valium) Most Recent Dose
Benzodiazepines (Valium) duration of use: Months / Years
Heroin *
Heroin Frequency
Heroin Amount
Heroin Most Recent Dose
Heroin duration of use: Months / Years
Prescribed mood-altering medications
Prescribed mood-altering medications Frequency
Prescribed mood-altering medications Amount
Prescribed mood-altering medications Most Recent Dose
Prescribed mood-altering medications duration of use Months / Years
Hallucinogens (LSD, Mushrooms, etc)
Hallucinogens (LSD, Mushrooms, etc) Frequency
Hallucinogens (LSD, Mushrooms, etc) Amount
Hallucinogens (LSD, Mushrooms, etc) Most Recent Dose
Hallucinogens (LSD, Mushrooms, etc) duration of use Months / Years
THC / Cannabis
THC / Cannabis Frequency
THC / Cannabis Amount
THC / Cannabis Most Recent Dose
THC / Cannabis duration of use Months / Years
6: Medical Detox
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 answer no or not sure
If you think you need certain medications, please explain why:
7: Behavioural Addiction Questionnaire
(Sex, Gambling, Gaming, Food (overeating / Bulimia / Anorexia), Self-Harming, Shopping / Spending, Co-Dependency / Love Addiction, Obsessive Compulsive, etc)
I Have A Behavioural Addiction
Please click what applies to you if you choose yes
Sex Addiction
Sex Addiction Consequences
Sex Addiction Length of issue
Gambling / Risk Taking
Gambling / Risk-Taking Consequences
Gambling / Risk-Taking Length of issue
Exercise
Exercise Consequences
Exercise Length of issue
Shopping / Spending / Debting
Shopping / Spending / Debting Consequences
Shopping / Spending / Debting Length of issue
Love Addiction
Love Addiction Consequences
Love Addiction Length of issue
Gaming
Gaming Consequences
Gaming Length of the issue
Overeating
Overeating Consequences
Overeating Length of issue
Obsessive Compulsive Disorders
Obsessive Compulsive Disorders Consequences
Obsessive Compulsive Disorders Length of issue
Co-dependency / Compulsive Helping
Co-dependency / Compulsive Helping Consequences
Co-dependency / Compulsive Helping Length of issue
Internet / Social Media
Internet / Social Media Consequences
Internet / Social Media Length of issue
Bulimia / Anorexia
Bulimia / Anorexia Consequences
Bulimia / Anorexia Length of issue
Behavioural Others
Others Description Here
Behavioural Others Consequences
Behavioural Others Length of issue
8: Trauma & Treatment Questionnaire
Do you believe you have unresolved Trauma that will benefit from treatment?
please your brief history here:
Do you identify specifically 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 many times?
Names of previous facilities & time spent at each
9: Mental Health
Have you ever received any mental health diagnosis (e.g. Depression, anxiety, bipolar, BPD, PTSD, etc): *
Please give any relevant details:
Do you have any history of self-harm, suicidal ideations or suicide attempts? *
please describe Briefly *
Do you have a criminal record, a history of violent behaviour or incarceration? *
DESCRIBE your Criminal behaviour Briefly *
Do you believe your actions were related to your addiction (i.e. fighting when drunk, or shoplifting to support your drug habit, etc?) *
Would you like to share more details about your current emotional well-being? *
If Yes, please briefly explain here:
10: Physical Health
Can you 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, stings, foods, etc)?
Do you have any medical records available to share with us (blood tests, BMI, detox history, etc)?
Doctors Report - upload documents here if applicable
Maximum file size: 512 MB
optional requests (not mandatory)
Doctor / GP Details
Name of Prescribing Doctor (GP or Psychiatrist, etc)
Doctor Telephone
Doctor E-Mail
Doctor Country Code
Current Diagnosis / Medication
List of any current medical health diagnosis
List any current non-prescribed medication:
List Any current Prescribed Medication
Prescribed Dosage & Frequency
Prescribed Reason For Taking
Travel & Dietary Information
Are you able to travel to our facility without assistance?
Details of Assistance Needed
Do you have any dietary requirements, including food allergies?
11: Insurance Information
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)
Upload Travel Insurance Here - Not Mandatory
Maximum file size: 512 MB
Insurance policy document or supporting info
How religious are you?
12: Treatment Start Date & Room
For Room Prices See
https://holinarehab.com/rehab-prices/
When do you want to come to treatment?
How long would you like to come to treatment?
Please Choose Your Room Type- All Prices + 7% Sales Tax
13: Treatment Funding
Person Funding Treatment:
Please Choose Your Method Of Payment
Our Wise Transfer Email is info@holinawellness.com
Who’s email address should we send our Wise invoice to?
Person Funding Full Name
Funders Address
Relationship to the individual:
E-Mail Address
Contact Phone
Contact Country Code
14: Further Information
How did you first hear about Holina? *
please tell us where you heard about holina *
15: Assessment Conformation - Final Step!
Do you confirm that all information on this assessment is true to the best of your knowledge? *
Please Type Your Full Name To Confirm The Assessment Then Press Submit *