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 *
Clients Contact Number
Country Code
Current Address Please
Date Of Birth
day / month / year
Email Address *
Do you have a valid Passport?
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
Contact Country Code
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
Contact Relationship To You
Emergency Contact Phone
Emergency Contact Country Code
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.
Please Give Your Reasons why if you answer no or not sure
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
Doctor Country Code
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)?
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