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Fill this form if you're struggling with an addiction, and we'll get back to you.
First Name
Last Name
Telegram ID (Optional)
Email
Phone
Date of Birth
Gender
Male
Female
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What do you struggle with
Pornography
Masturbation
Drugs / Substance Abuse
Smoking
Other
Tell us briefly how it started (Optional)
How bad is it?
I do this ocassionally
I do this frequently
I can't go a day without doing this
Are you willing to let this go?
Yes
No
Not Sure
Can you fast?
Yes
No
Not Sure
Will you help others when you get free?
Yes
No
Not Sure
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