Addiction Treatment Center

12 Step Holistic Resort

Holina Assessment

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.

Personal Details
Please Fill In Your Details Below
Full Name *
Nationality *
Clients Contact Number *
Please Include Country Code ie 44 (UK), 61 (AUS), 01 (CAN/US) etc
Current Address Please Include Post Code
Date Of Birth *
Email Address *
Do you have a valid Passport?
Gender *
Do You Speak English? *
Do you understand that treatment is delivered in English?
Current Living Arrangement *
Reasons For Treatment
Please Fill In Your Details Below
In your own words, what is your reason for wanting to come to Holina?
Family & Marital Status
Please Give As Much Details As Possible
Do You Have Children or Dependents: *
Number Of Children *
Describe Your Current Relationship With Your Family
Sexual Orientation
Other Details
Treatment Funding
Person Funding Treatment:
Person Funding Full Name *
Contact Phone *
Please Include Country Code ie 44 (UK), 61 (AUS), 01 (CAN/US) etc
Relationship to the individual: *
E-Mail Address *
Funders Address
Please Choose Your Method Of Payment
Emergency Contact
Please Provide Details Below
Emergency Contact Full Name *
Emergency Contact E-Mail
Emergency Contact Phone *
Please Include Country Code ie 44 (UK), 61 (AUS), 01 (CAN/US) etc
Contact Relationship To You
Substance Addiction Questionnaire
Substances being used currently and historically, including Alcohol and Prescription Medication
I Have A Substance Addiction *
Please click what applies to you
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)
Other Opiates (Methadone / Suboxone) Frequency *
Other Opiates (Methadone / Suboxone) Amount *
Other Opiates (Methadone / Suboxone) Most Recent Dose *
Other Opiates (Methadone / Suboxone) 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 Frequency *
Ketamine Amount *
Ketamine Most Recent Dose *
Ketamine duration of use Months / Years *
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 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
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 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 *
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.
If you think you need certain medications, please explain why:
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
Sex Addiction
Sex Addiction Consequences *
Sex Addiction Length of issue *
Gambling / Risk Taking
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
Love Addiction Consequences *
Love Addiction Length of issue *
Gaming Consequences *
Gaming Length of the issue *
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 *
Doctor / GP Details
Name of Prescribing Doctor (GP or Psychiatrist, etc)
Doctor Telephone
Please Include Country Code ie 44 (UK), 61 (AUS), 01 (CAN/US) etc
Doctor E-Mail
Current Diagnosis / Medication
List of any medical health diagnosis
List Any Prescribed Medication
Prescribed Dosage & Frequency
Prescribed Reason For Taking
List any non-prescribed medication:
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? *
Do you have any medical records available to share with us (blood tests, BMI, detox history, etc)? *
Upload Files Here
Maximum file size: 2 MB
Are you mobile and able to walk unassisted? *
Do you have any allergies (medications, stings, foods, etc)? *
Treatment History
Have you been in treatment before?
If YES, how many times?
Names of previous facilities & time spent at each
Treatment Experience
Do you believe you have experienced any traumatic events in your life? (e.g. physical, emotional, sexual, domestic violence)
Have you ever received any mental health diagnosis (e.g. Depression, anxiety, bipolar, BPD, PTSD, etc):
Please give any relevant details: *
Trauma & Mental Health
Do you have any history of self-harm, suicidal ideations or suicide attempts?
Briefly Describe
Do you have a criminal record, a history of violent behaviour or incarceration?
Criminal Briefly Describe
Do you believe your actions were related to your addiction (i.e. fighting when drunk, or shoplifting to support my drug habit, etc?)
Religious Beliefs
Religious Beliefs
Religious Beliefs Description
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?
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)
Treatment Start Date & Room
For Room Prices See
When do you want to come to treatment?
Please Choose Your Room Type
Further Information
How did you first hear about Holina?
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 *

How Much Does Holina Cost?

We have a wide selection of accommodation options available when you stay at Holina Rehab, Koh Phangan. We believe your environment and the people around you can make a big difference in your treatment and your overall well-being.

Please enquire about the pricing structure of 24/7 medically managed detox, supervised by Doctors and nurses, licensed as an inpatient hospital on the contact form below.

Holina Morning Routine

Holina Acvite

Holina Inner Walk