Intake – Holina Healing Centre – Wellness Resort in Khao Yai, Thailand

Holina Healing Intake Form

Phone

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

Personal Information

Please share your personal information. This information is confidential, secure and safely stored.

First Name(Required)

First

Last Name(Required)

Last

Date of Birth(Required)

Phone Number(Required)

Email Address(Required)

Age(Required)

Nationality(Required)

Passport Number(Required)

Do You Speak English?(Required)

Do You Understand Treatments are In English?(Required)

Home Address(Required)

Gender(Required)

Marital Status(Required)

Do you have children or dependents? If so, how many?

In your own words, what is the reason you want to come to Holina Healing Centre?

Mental Health Assessment

Have you been diagnosed with any mental health conditions, such as depression, anxiety, trauma, PTSD, or others? If so, please list them.

Are you currently taking any medications for your mental health? If so, please specify names and dosages.

Have you experienced significant changes in your mood, thoughts, or behavior in the past 6 months? If so, please describe.

Do you engage in self-harm behaviors, such as cutting, burning, or substance use? If so, please explain.

Do you have any history of violent behavior? If yes, please specify the nature of the behavior:

How frequently do you experience intrusive thoughts, flashbacks, or nightmares related to past traumatic events?

Do you have difficulty regulating your emotions or managing intense feelings? If so, please describe.

Have you ever received professional help for your mental health, such as therapy or counseling? If so, please describe your experience.

Have you ever vomited or used laxatives to lose weight or purge food you have eaten?

Do you consume a small amount of food (i.e., less than 1200 calories/day) on a regular basis to influence your shape or weight?

Have you ever been diagnosed with an eating disorder?

If so, what?

Do you have any dietary needs or restrictions? If yes, please specify:

Emotional Health Assessment

On a scale of 1 to 10, how would you rate your overall emotional state? (1 is worst, 10 is excellent)

Do you have difficulty expressing or identifying your emotions? If so, please explain.

How do you typically cope with difficult emotions or stressful situations?

Have you experienced any significant losses, such as the death of a loved one, the end of a relationship, or job loss? If so, please describe how you were affected.

Have you had any suicidal thoughts in the past weeks or days or currently?

When was the last time you had suicidal thoughts?

Was intent associated with the suicidal thought(s)?

Have you made a plan on how you would kill yourself?

Do you have a history of suicide attempts?

Please specify (how many attempts, method for each, and when):

Do you have a strong support system of family, friends, or community? If so, please describe.

Spiritual and Cultural Practices

Do you have spiritual or religious beliefs that are important to you? If so, please describe.

Do you engage in any spiritual or cultural practices, such as meditation, prayer, or rituals? If so, please explain.

Have your spiritual or cultural beliefs played a role in your healing process or in coping with trauma? If so, please describe.

Are there cultural or spiritual traditions you would like to incorporate into your treatment plan?

Medical History

Do you have any chronic physical health conditions, such as chronic pain, autoimmune disorders, or neurological conditions? If so, please list them.

Have you experienced any significant physical injuries or accidents in your life? If so, please elaborate.

Are you currently taking any medications for your physical health? If so, please list names and dosages.

Have you ever been hospitalized or undergone any major medical procedures? If so, please describe.

Do you have any allergies or sensitivities we should be aware of?

Do you have any past or recent injuries that may affect your mobility? If yes, please specify:

Do you have a history of seizures?

Were you given an associated diagnosis? (e.g., Epilepsy):

Type of Trauma

What type of traumatic events have you experienced in your life such as abuse, neglect, injury, emotional, physical or spiritual abuse, witnessing catastrophes or war?

Does your family have a history of addiction, mental health and/or trauma related related events? If yes, please identify below:

When did the traumatic events occur? How long ago?

How have the traumatic events affected your life, both immediately after the event and in the long term?

Additional Information

Have you previously been in any treatment or therapeutic center? Please specify.

Do you use substances that alter consciousness and mood? (alcohol, drugs, pills, psychedelics, etc.) If so, please list the quantities and frequency of their use.

Are you willing to stop using them during your stay at Holina Healing Centre?

Have you ever been convicted of a crime? If yes, when and please specify the crime:

Do you have a current legal issue pending / in process? If yes, please specify the nature of the legal issue:

What are your main goals or expectations for treatment at our center?

Which plan are you interested in?

5% discount if committed to 2 months prior to arrival . 15% discount if committed to 3 months prior to arrival.

How long do you anticipate coming for?

What date do you anticipate joining the Holina Healing Program?

Any preference regarding therapist (e.g., gender)?

Who will be paying for treatment if admitted to the Holina Healing program?

First Name of Payer

Last Name of Payer

Phone Number of Payer

Email Address of Payer

Is there any other information about your background, experiences, or current situation that you would like to share with us?

How Did you First Hear About Holina?(Required)

Please Specify:

Assessment Confirmation(Required)

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. Thank you for taking the time to complete this comprehensive self-assessment questionnaire. Your responses will be carefully reviewed, and we will work with you in close collaboration to develop a personalized treatment plan that addresses your unique needs and supports your healing journey.(Required)

Holina Assessment

Holina Healing Intake Form

Personal Information

Mental Health Assessment

Emotional Health Assessment

Spiritual and Cultural Practices

Medical History

Type of Trauma

Additional Information

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