Thai Rehabs Survey Form

Thai Rehabs Client Survey

To help us understand your needs so we can respond with rehabs that are a good match for you, please complete the following for to the best of your ability.
Your Personal Data

For privacy reasons, we only need your first name, email and age - if you would like to complete your surname and phone number, that is up to you. The information you provide is confidential and will be used by our team to help match your needs with suitable Thai Rehabs.
Name*

First Name
Email*
example@example.com
What is your age?*
Some rehabs have a preferred age limit
Phone Number

Country CodeArea CodePhone Number
Your rehab preferences

This will help us refine the rehab choices that we submit to you for consideration
What is the main concern (click as many issues as needed)

Alcohol AddictionDrug AddictionPrescription Medication AddictionBehavioural Addiction (e.g. gambling, sex, internet, shopping, eating etc.)Mental Health IssueI have no substance related issuesOther
If you ticked "Other" could you describe other?
How long have you had substance use disorder issues?

Less than 1 yearBetween 1 and 5 yearsBetween 5 and 10 years10 years or more
Will you require a medical detox?

Yes, I believe I will need medication to help manage my withdrawalsNo, I will not need a medical detoxI am not sure if I will need a detox - I will need to be assessed
Have you been diagnosed any mental health conditions? Please click what applies

AnxietyDepressionTrauma or PTSDSchitzophreniaBi-PolarOCDADHDBorderline Personality DisorderOther
If you ticked "Other", please describe in more detail
Are you taking any medication currently?

YesNoYes, but I am not fully compliantNo, but I would like to evaluate my needs during my Psychiatric assessment
Please click the facility options that would be important to you in a rehab (click as many as necessary)

Swimming PoolPrivate Room (air conditioned)Smart television in my roomWIFI 24 hours per dayKeeping my phone and computer with me (not all rehabs allow this)Fitness options (e.g. mountain bikes, gym, Thai boxing)Holistic options (e.g. Yoga, massage, meditation, Reiki)Weekly excursions to enjoy Thailand (accompanied by Thai staff always)Other
If you ticked "Other", please describe in more detail
What size of rehab do you prefer?

Smaller sized rehab of 10 or less clientsMedium sized rehab of 10 - 20 clientsLarger sized rehab with 20+ clientsNo real preference on rehab size
What sort of rehab treatment modality do you prefer?

I prefer a 12-step based treatment modelI prefer an evidence based Cognitive Behavioural Therapy (CBT) programI do not really have a preference
What sort of treatment length are you considering?

A standard 28-day programBetween 28-day and 2-month programProbably a 3-month programI'm not sure yet and will take advice from the rehab
Do you have any mobility issues?

NoSome. Prefer to not have to walk too farYes, I have some mobility issues that affect my movementYes, I require wheelchair access
Have you been to rehab previously?

Yes, I haveNo, I have not
If you ticked "Yes", how many rehabs have you attended in the past?
Do you have any food preferences

No, I'll eat most thingsI am a veganI am a vegetarianI have certain foods I cannot eat (more details will be requested later)I require Halal mealsI require Kosher mealsOther
If Other, please let us know if you can
Do you have a rehab budget in mind? (Price is not an indicator of value or quality)

I prefer a budget rehab (USD$5,000 - $7,500)I prefer a moderate prices rehab (USD$7,500 - $12,500)I prefer a more high end luxury rehab (USD$12,500 - $20,000)I just want the best rehab for me based on my required needs
If you have anything else that you would like to add, please do so here.
If you have any files you wish to include that may be helpful, please do so here.

Cancelof
How would you like us to refer recommended Rehabs?

Please just send me some detail via email and I will manage myselfPlease provide this form to recommended rehabs and they can contact mePlease call me to discuss your recommendation and next steps
Click this button if you would like us to call you by phone to discuss your needs further

Yes, please call me on the number provided above
Click this button if you would like us to send you a PDF copy of your completed survey to use as you need.

Yes, please send me a copy of my completed survey to my email above
Thank You for taking the time to complete this form

We will get back to you as quickly as we can with 2 - 3 rehabs that we believe will suit your requirements.
Important Note About Our Recommendations
At Thai Rehabs, we base our recommendations solely on the information you provide. We only suggest rehab centers that are fully licensed and accredited by the Ministry of Public Health in Thailand and have a proven track record of delivering quality care to past clients.

Please be aware that Thai Rehabs is not responsible for the services, communication, treatment programs, pricing, or refund policies of any rehab facility we recommend, and it is important that you conduct your own due diligence on any rehab(s) that Thai Rehabs recommend. We act as an independent referral service, and all final decisions and arrangements are made directly between you and the rehab center.
Should be Empty:

Thai Rehabs Client Survey

Your Personal Data

Your rehab preferences

Thank You for taking the time to complete this form