Addiction Treatment Center

12 Step Holistic Resort

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

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 *

Yes

Please click what applies to you

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 *

Yes

Please click what applies to you

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? *

Yes

Do you have any medical records available to share with us (blood tests, BMI, detox history, etc)? *

Yes

Upload Files Here

Maximum file size: 2 MB

Are you mobile and able to walk unassisted? *

Yes

Do you have any allergies (medications, stings, foods, etc)? *

Treatment History

Have you been in treatment before?

Yes

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 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

https://holinarehab.com/rehab-prices/

When do you want to come to treatment?

Further Information

Assessment Conformation - Final Step!

Do you confirm that all information on this assessment is true to the best of your knowledge?

Yes

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.