Clinician & Professional Referral | Holina Village Cyprus

Step 1 of 3

Facebook

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

Client's Information

Please share your personal information

First Name(Required)

First

Last Name(Required)

Last

Are you looking to join the Adult program or the Young Persons program?

Adults is suitable for ages 24 + and Young Persons program is up to age 25.

Age at this time(Required)

Last

Date of Birth(Required)

Phone Number(Required)

Email Address(Required)

Nationality(Required)

Do you have a valid passport?(Required)

Passport Number(Required)

Gender(Required)

Sexual Orientation

What is your current residential address?

Do You Speak English?(Required)

Do You Understand Treatment Is In English?(Required)

Current Living Arrangement?

Do You Have Children or Dependents?

Number of Children or Dependents

Describe Your Current Relationship With Your Family(Required)

Emergency Contact Full Name(Required)

Contact Relationship To You(Required)

Emergency Contact Email(Required)

Emergency Contact Phone Number(Required)

Trauma & Emotional Disregulation

Do you believe you have unresolved trauma that will benefit from treatment?(Required)

Please Explain Your History Here

Do you have other Emotional or Behavioural challenges? If so please describe them here.

Therapy History

Have You Been in Therapy Before?(Required)

How Long Were You In Therapy?

What Type of Therapies Have You Engaged With?

Have You Been in Residential Rehabilitation Before?(Required)

Please List the Names of Previous Facilities

Did you complete the full program there?

Mental Health

Have You Ever Received Any Mental Health Diagnosis? (Depression, Anxiety, Bipolar, BPD, Schizophrenia, PTSD, etc)(Required)

Please Give Any Relevant Details

Do You Have Any History of Self-Harm?(Required)

Please describe your self harming

Do You Have Any History of Suicidal Ideations or Suicide Attempts?(Required)

Please Explain and Include a Timeline in the Case of Any Attempts

Would You Like to Share More Details About Your Current Emotional Well-Being?(Required)

Briefly Explain More About Your Emotional Well-Being

Criminal History

Do You Have a Criminal Record or a History of Incarceration?(Required)

Please Describe Your Criminal Behaviour

Do You Have a History of Violent Behaviour?(Required)

Please Describe Your Violent Behaviour

Do You Have any History as a perpetrator of any sexual violence?(Required)

Note: we may be unable to accept you at Holina if you have such a history.

Physical Health

Can You Please Give Us As Much Detail As Possible Concerning Your Current Physical Health? Include Any Current and Historic Problems You May Have:(Required)

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)?

If so please email them to richard.pike@holinakpg.com as early as possible.

Do You Have Any Allergies (Medications, Animals, Stings, etc)?(Required)

Do You Have Any Dietary Requirements, Including Food Allergies?(Required)

Do you need a Kosher or Halal diet?

Additional cost of + â‚¬1,600 / mo.

Are You Mobile and Able to Walk Unassisted? [Can you walk up & down stairs?](Required)

Are You Able to Travel to Our Facility Without Assistance?

Name of Prescribing Doctor (GP or Psychiatrist, etc)

Doctor Phone Number

Doctor Email

Are you currently on any prescription medications?(Required)

List Prescribed Medication #1

Prescribed Reason For Taking

Prescribed Dosage Per Day

List Prescribed Medication #2

Prescribed Reason For Taking

Prescribed Dosage Per Day

Are you currently on any non prescription medications?

List Non Prescribed Medication #1

Non Prescribed Reason For Taking

Non Prescribe Dosage Per Day

List Non Prescribed Medication #2

Non Prescribed Reason For Taking

Non Prescribe Dosage Per Day

Please Provide the Details of Assistance Needed

Final 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 Cyprus longer than anticipated)(Required)

When Do You Want to Come to Treatment?(Required)

New admissions are Monday before 3pm only.

Can you commit to 12 weeks?(Required)

How many weeks are you intending on coming for?(Required)

Which room type would you like?(Required)

Person Funding Treatment

Funding Person's Name

Funding Person's E-mail

Funding Person's Contact

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(Required)

Start Your Intake Assessment

How this works: