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+32 (0) 480 67 40 18 contact@affect2u.be

LOCATIONS TESTIMONIALS CONTACT

FROM SURVIVING TO LIVING

English

Vlagicoon voor het wisselen naar de Engelse taalversie van de site.

Nederlands Vlagicoon voor het wisselen naar de Nederlandse taalversie van de site.

Reach out now

Discreet & fast admission

+32 (0) 480 67 40 18

info line from 7 a.m. to 8 p.m., 7/7

Alcohol addiction

Gaming addiction

Gambling addiction

Sex or porn addiction

Multiple addictions

Types of trauma

Post-traumatic stress disorder (PTSD)

Extended Care Program

Outpatient care

Guidance for loved ones

Our vision Our mission Our values Our team

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Before your admission

/pre-intake questionnaire

Residential pre-intake questionnaire

This form helps us get to know you better, understand your background and determine whether our residential programme may be the right fit for you at this stage. It also helps us prepare for your intake conversation and make better use of that time.
You do not need to share every detail of your trauma here.
If a question feels too personal or difficult to answer, you may simply indicate that you prefer not to respond.

01 Basic information

Name:

Date of birth:

Preferred name:

E-mail:

Phone:

Current country of residence:

I agree to the price of the intake interview of €235

Street address:

Zip:

City:

Emergency contact person (name, relation, phone):

Referring source (tick one):selfFamilyDoctor/PsychiatristJusticeOther treatment center

Other:

02 Legal and practical status

Are you going to start treatment voluntarily?YesNo, please explain briefly:Are there any pending or upcoming legal matters that we need to be aware of?noYes, please explain briefly:Are there any conditions attached to your admission (justice, probation, visa, etc.)?noYes, please explain briefly:Do you need a report for your insurance?noYes, please explain briefly:

03 Why now?

Please answer succinctly.

What prompted you to currently seeking residential treatment in your life?

What do you hope will be different after completing the treatment?

04 Substance Abuse and Compulsive Behavior

Resource (s) you're having trouble with:AlcoholCocaineHeroin/OpioidsAmphetamineMethamphetamineCannabisBenzodiazepinesPrescribed medication

Others:

Behavioral addiction (s) you're struggling with:GamblingPorn/sexGamingEatBuyInternet/Social media

Others:

Usage pattern for your main agent/behavior of choice:

Last use/behavior (approximate):

Typical pattern of use/behavior (daily/in flurries/occasional):

Typical pattern of use/behavior in the last 30 days (daily/at times/occasionally):

Longest period of abstinence in the past:

What is usually the reason for a relapse or loss of control over your substance use?

What is the function of your use?

05 Previous treatments

Have you had treatment for addiction or mental health problems in the past?noYes, please list briefly (where, when, duration, result):

Have you ever been diagnosed with a mental disorder? If so, when and by whom?

06 Mental Health Signals

Please check what applies to you (currently and in the past):GamblingfearsPanic attacksPTSD/complex traumaPsychosisBipolar disorderADHDEating disorderNothing determined

Other experiences (check if relevant):Memory loss/blackoutsDissociation/a sense of unreality or detachmentStrong mood swingsImpulsive or risky behavior

07 Safety check

Answer honestly — that helps us keep everyone safe.

Have you ever had suicidal thoughts?noIn the pastCurrently

Have you ever attempted suicide?noYes (no details required)

History of self-harm?noYes

History of violence against others?noYes

If you answered “yes” to any of these questions, is there anything else important we need to know before we meet you?

08 Medical considerations

Check everything that applied now or in the past:attackingDelirium tremensWithdrawal complicationsHead injuriesChronic illnessDiabetesHeart disease

Others

Current prescription medication (s):

Prescribing physician (if applicable):

What is your height

What is your weight?

09 Relationships and support

Who currently supports you the most?

Are there relationships that destabilize you greatly?

Do you have dependents (children or others)?no

Yes

10 Compliance with the Affect2U Residential Program

Our program is:

Group-oriented and relational
Trauma-informed
Emotionally focused
Requires shared responsibility, boundaries, and community living together
It's not just about quitting substance use, but also about inner change.

What do you think of this approach?This suits me wellUncertain but openI have a number of concerns (please explain):

11 Willingness and dedication

On a scale of 0 to 10, how ready do you feel to participate in residential treatment?

What could make it difficult for you to be fully engaged?

What strengths do you bring to the treatment?

12 Is there anything else we need to know before we meet?

Declaration

I confirm that the information provided is accurate to the best of my knowledge.

Name:

Datum:

Thank you.
A team member will review your responses before your intake interview.

Something went wrong. Please try again.

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From Surviving to Living

Addictions

Alcohol addiction

Drug addiction

Gaming addiction

Gambling addiction

Sex or porn addiction

Work addiction

Multiple addictions

Dual diagnosis

Trauma

Types of trauma

Burnout

Depression

Post-traumatic stress disorder (PTSD)

Treatments

Residential admission

Aftercare

Extended Care Program

Outpatient care

Detox

Family support

I'm looking for help

for myself

for my client

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