The James Affect Life Transformation Program

Personal details

Basic information so we know how to welcome you

First name *

Last name *

Date of birth *

Nationality

Email address *

Phone / WhatsApp

Preferred name or nickname

What should our team call you during your stay?

Emergency contact name & phone

What brings you here

We want to understand your story and what you're hoping for

Your answers are confidential. Please be as open as you feel comfortable with — honesty helps us help you.

In your own words, what has brought you to this program?

How long have you been aware that something needed to change?

What have you already tried? (select all that apply)

Therapy or counselling Medication or medical support 12-step or support groups Previous residential program Self-help, books, online courses Mindfulness, yoga, or spiritual practice Nothing yet — this is my first step

What made you choose The James Affect Life Transformation program? I'm curious…

Substances & behaviours

Helps us prepare the right clinical and therapeutic support

This section is reviewed only by licensed clinical staff. Complete accuracy ensures your safety during detox or withdrawal phases.

Primary concern (select the most important one)

Alcohol Opioids / prescription painkillers Stimulants (cocaine, methamphetamine, etc.) Cannabis Benzodiazepines / sleeping pills Behavioural (gambling, eating, technology, sex) General burnout / mental health Other

How would you describe your current daily use or behaviour?

When did you last use / engage in the behaviour above?

Have you experienced withdrawal symptoms before?

Yes, significant — shaking, seizures, or hospitalisation Yes, mild — nausea, sweating, anxiety No, or unsure

Any other substances or behaviours we should know about?

Health & medical history

So our medical team can prepare the safest care plan for you

Current medications (name + dose if known)

Known medical diagnoses or conditions

Mental health diagnoses (current or past)

Any history of self-harm or suicidal thoughts?

We ask everyone — this helps us ensure you have the right support nearby.

Yes, currently Yes, in the past, not currently No Prefer to discuss in person

Allergies or dietary requirements

Any physical limitations we should plan around?

Life context

Helps us understand what you're coming from and returning to

Current living situation

Family or relationship factors you'd like us to know about

Current employment or life situation

Is there anything in your environment that may be a trigger or obstacle to recovery?

Goals & preferences

So we can shape the right program experience for you

What does transformation look like for you? What would make this a success?

Which areas matter most to you? (select up to 3)

Emotional healing & trauma work Physical health & body restoration Rebuilding relationships Finding meaning & purpose Developing daily structure & habits Career & financial wellbeing Spiritual or existential exploration

Anything else you'd like your team to know before you arrive?

Thank you — you're all set

Your questionnaire has been received. A member of your care team will review your answers before you arrive and may be in touch with a few follow-up questions.

We look forward to welcoming you.

The James AffectLife Transformation Program

Thank you — you're all set

The James Affect
Life Transformation Program