Freedom from harmful habits and addictions Participant- Questionnaire

Telephone number? _______________________

• telegram or signal phone number? ______________________(if different from 1)
• E-mail address? _____________________-
• what day did you arrive in Yuyo?
• when do you want to leave? _________________
• room? Chilamate o Tucan (underline the room you stay)
• are we allowed to take pictures and/or videos of you with prior notice, for example, during your activities here? ________ (Yes/No)
• may we publish them on our website, e.g. if they turn out well? _____ (Yes/No)
• You want to be part of the Telegram group Yuyo-volonteer-community? _____ (Yes/No)
• are there any medical conditions we should be aware of, e.g. allergies, etc.? ________ (yes/no)
• if yes, which ones? _____________________________________________________
• What is the harmful behaviour you would like to get rid of (e.g. drugs, cigarettes, licor, over-eating, gambling, pornografy, etc.)?
  if more than one please prioritize which one you consider is the most important for you to get rid of.
  • 1)______________________________________________________
  • 2) _____________________________________________________
  • 3) ______________________________________________________