TheAAC.co.za visitor survey.
Please answer all the questions honestly.All submissions will remain 100% confidential.
Full Names (optional)
Your Email Address (optional)
Age
Sex
Male
Female
Province
Gauteng
Mpumalanga
Kwazulu Natal
Free State
North West
Limpopo
Western Cape
Northern Cape
Eastern Cape
Are you emploed
Yes
No
Self employed
Retired
Are you struggling a dependency?
Yes
No
Not sure
Someone else is
Why did you visit our site?
Info on drugs
Info on alcohol
Info on gambling
Info on porn
Info on sex
For a rehab
For detox
Info on legislation
Other
How did you find us?
Google search
Yahoo search
MSN search
You were recommended
Saw a link on Google
Link from another site
Did you find what you were looking for?
Yes
No
What would you like more info on?
Where must we send it to? (emaill address)
Must sin tax be used for treatment costs?
Yes
No
Not all but more
Who is accountable for treatment costs?
The government
Supplying companies
The individual
Have you used drugs before?
Yes
No
Are you using drugs now?
Yes
No
Do you have children?
Yes
No
How many?
1
2
3
4
5
6
7
More
Marital status
Single
Divorced
Separated
Widowed
Have you finished high school?
Yes
No
Still busy
Do you have a tertiary education?
Yes
No
Still busy
Do you drink alcohol?
Yes
No
Used to
Do you smoke cigarettes?
Yes
No
Used to
Are you considering using drugs or alcohol?
Yes
No
Do you think you have a problem with..
Drugs
Alcohol
Sex
Gambling
Porn
Spending
Sleeping
Working
Masturbation
Multiple areas
All of the above
Image Verification
Please enter the text from the image
:
[
Refresh Image
] [
What's This?
]
Powered by
EMF
Web Form
EMF Web Form
EMF Web Form