{"id":9927,"date":"2024-03-20T15:29:24","date_gmt":"2024-03-20T19:29:24","guid":{"rendered":"https:\/\/teenchallengepr.org\/?page_id=9927"},"modified":"2025-01-02T11:51:02","modified_gmt":"2025-01-02T15:51:02","slug":"cuestionario-de-ingreso","status":"publish","type":"page","link":"https:\/\/teenchallengepr.org\/en\/cuestionario-de-ingreso\/","title":{"rendered":"Cuestionario de Ingreso"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"9927\" class=\"elementor elementor-9927\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8c1b6b2 elementor-section-content-top ot-traditional elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"8c1b6b2\" data-element_type=\"section\" data-e-type=\"section\" id=\"enviarsolictud\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-add1e18 ot-flex-column-vertical\" data-id=\"add1e18\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-44cb1c7 elementor-widget elementor-widget-heading\" data-id=\"44cb1c7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Submission of online application<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fded9e7 elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"fded9e7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script type=\"text\/javascript\" src=\"https:\/\/teenchallengepr.org\/wp-includes\/js\/dist\/dom-ready.min.js?ver=f77871ff7694fffea381\" id=\"wp-dom-ready-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/teenchallengepr.org\/wp-includes\/js\/dist\/hooks.min.js?ver=dd5603f07f9220ed27f1\" id=\"wp-hooks-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/teenchallengepr.org\/wp-includes\/js\/dist\/i18n.min.js?ver=c26c3dc7bed366793375\" id=\"wp-i18n-js\"><\/script>\n<script type=\"text\/javascript\" id=\"wp-i18n-js-after\">\n\/* <![CDATA[ *\/\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n\/\/# sourceURL=wp-i18n-js-after\n\/* ]]> *\/\n<\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/teenchallengepr.org\/wp-includes\/js\/dist\/a11y.min.js?ver=cb460b4676c94bd228ed\" id=\"wp-a11y-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/teenchallengepr.org\/wp-includes\/js\/jquery\/jquery.min.js?ver=3.7.1\" id=\"jquery-core-js\"><\/script>\n<script type=\"text\/javascript\" src=\"https:\/\/teenchallengepr.org\/wp-includes\/js\/jquery\/jquery-migrate.min.js?ver=3.4.1\" id=\"jquery-migrate-js\"><\/script>\n<script type=\"text\/javascript\" defer='defer' src=\"https:\/\/teenchallengepr.org\/wp-content\/plugins\/gravityforms\/js\/jquery.json.min.js?ver=2.9.19.3\" id=\"gform_json-js\"><\/script>\n<script type=\"text\/javascript\" id=\"gform_gravityforms-js-extra\">\n\/* <![CDATA[ *\/\nvar gf_global = {\"gf_currency_config\":{\"name\":\"U.S. Dollar\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"},\"base_url\":\"https:\/\/teenchallengepr.org\/wp-content\/plugins\/gravityforms\",\"number_formats\":[],\"spinnerUrl\":\"https:\/\/teenchallengepr.org\/wp-content\/plugins\/gravityforms\/images\/spinner.svg\",\"version_hash\":\"902281c437dc270f332a391f2b70f202\",\"strings\":{\"newRowAdded\":\"New row added.\",\"rowRemoved\":\"Row removed\",\"formSaved\":\"The form has been saved.  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indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9' class='gf_stylespro sp_chisel' action='\/wp-json\/wp\/v2\/pages\/9927' data-formid='9' novalidate data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/9927\">\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_46\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_46'>Facebook<\/label><div class='ginput_container'><input name='input_46' id='input_9_46' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_9_46'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_9_13\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_13'>Contact location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_9_13' class='medium gfield_select'  aria-describedby=\"gfield_description_9_13\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Detox(cl\u00ednica de Buprenorfina)' >Detox(cl\u00ednica de Buprenorfina)<\/option><option value='Hogar Hombres' >Hogar Hombres<\/option><option value='Hogar Damas' >Hogar Damas<\/option><option value='No estoy seguro' >I&#039;m not sure<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_9_13'>At what location you&#039;d like to send this request?<\/div><\/div><fieldset id=\"field_9_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00a1Bienvenido\/a a Teen Challenge Puerto Rico! Para empezar, \u00bfcu\u00e1ntos a\u00f1os tienes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_19'><div class='gchoice gchoice_9_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Menos de 18 a\u00f1os'  id='choice_9_19_1'   aria-describedby=\"gfield_description_9_19\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_1' id='label_9_19_1' class='gform-field-label gform-field-label--type-inline'>Menos de 18 a\u00f1os<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Entre 18 y 60 a\u00f1os'  id='choice_9_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_2' id='label_9_19_2' class='gform-field-label gform-field-label--type-inline'>Entre 18 y 60 a\u00f1os<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='M\u00e1s de 60 a\u00f1os'  id='choice_9_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_3' id='label_9_19_3' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de 60 a\u00f1os<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Todas las anteriores'  id='choice_9_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_19_4' id='label_9_19_4' class='gform-field-label gform-field-label--type-inline'>All of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_19'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nos interesa conocerte mejor, \u00bfcu\u00e1l es tu sexo de nacimiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_20'><div class='gchoice gchoice_9_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Hombre'  id='choice_9_20_1'   aria-describedby=\"gfield_description_9_20\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_1' id='label_9_20_1' class='gform-field-label gform-field-label--type-inline'>Hombre<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Mujer'  id='choice_9_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_2' id='label_9_20_2' class='gform-field-label gform-field-label--type-inline'>Mujer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Prefiero no decir'  id='choice_9_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_3' id='label_9_20_3' class='gform-field-label gform-field-label--type-inline'>Prefiero no decir<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_20'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Estamos aqu\u00ed para ti, desde cualquier lugar. \u00bfDe d\u00f3nde nos escribes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_41'><div class='gchoice gchoice_9_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Norte de Puerto Rico'  id='choice_9_41_1'   aria-describedby=\"gfield_description_9_41\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_41_1' id='label_9_41_1' class='gform-field-label gform-field-label--type-inline'>Norte de Puerto Rico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='Sur de Puerto Rico'  id='choice_9_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_41_2' id='label_9_41_2' class='gform-field-label gform-field-label--type-inline'>Sur de Puerto Rico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Este u Oeste de Puerto Rico'  id='choice_9_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_41_3' id='label_9_41_3' class='gform-field-label gform-field-label--type-inline'>Este u Oeste de Puerto Rico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='De los Estados Unidos (indica el estado)'  id='choice_9_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_41_4' id='label_9_41_4' class='gform-field-label gform-field-label--type-inline'>De los Estados Unidos (indica el estado)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_41'>Elige solo una opcion<\/div><\/fieldset><div id=\"field_9_26\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_26'>La comunicaci\u00f3n es clave. \u00bfCu\u00e1l es tu n\u00famero de tel\u00e9fono?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_9_26' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_28\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_28'>Mantenernos en contacto es importante. \u00bfTu correo electr\u00f3nico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_28' id='input_9_28' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_9_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Comparte tu historia, \u00bfCu\u00e1l es tu condici\u00f3n de adicciones?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_21'><div class='gchoice gchoice_9_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='S\u00ed, quiero compartir'  id='choice_9_21_1'   aria-describedby=\"gfield_description_9_21\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed, quiero compartir<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Prefiero en privado'  id='choice_9_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_2' id='label_9_21_2' class='gform-field-label gform-field-label--type-inline'>Prefiero en privado<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='No estoy seguro\/a'  id='choice_9_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_3' id='label_9_21_3' class='gform-field-label gform-field-label--type-inline'>No estoy seguro\/a<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_21'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfQu\u00e9 tipo de sustancias est\u00e1s utilizando actualmente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_42'><div class='gchoice gchoice_9_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Alcohol'  id='choice_9_42_1'   aria-describedby=\"gfield_description_9_42\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_42_1' id='label_9_42_1' class='gform-field-label gform-field-label--type-inline'>Alcohol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='Drogas ilegales (por favor especifica cu\u00e1l)'  id='choice_9_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_42_2' id='label_9_42_2' class='gform-field-label gform-field-label--type-inline'>Drogas ilegales (por favor especifica cu\u00e1l)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='Medicamentos recetados'  id='choice_9_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_42_3' id='label_9_42_3' class='gform-field-label gform-field-label--type-inline'>Medicamentos recetados<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_42'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nos ayuda conocer la cantidad aproximada que usas.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_43'><div class='gchoice gchoice_9_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Ocasionalmente'  id='choice_9_43_1'   aria-describedby=\"gfield_description_9_43\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_43_1' id='label_9_43_1' class='gform-field-label gform-field-label--type-inline'>Ocasionalmente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Diariamente'  id='choice_9_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_43_2' id='label_9_43_2' class='gform-field-label gform-field-label--type-inline'>Diariamente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Varias veces al d\u00eda'  id='choice_9_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_43_3' id='label_9_43_3' class='gform-field-label gform-field-label--type-inline'>Varias veces al d\u00eda<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_43'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tu bienestar es nuestra prioridad, \u00bftienes plan m\u00e9dico de la reforma?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_30'><div class='gchoice gchoice_9_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='S\u00ed'  id='choice_9_30_1'   aria-describedby=\"gfield_description_9_30\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_30_1' id='label_9_30_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='No'  id='choice_9_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_30_2' id='label_9_30_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='En proceso'  id='choice_9_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_30_3' id='label_9_30_3' class='gform-field-label gform-field-label--type-inline'>En proceso<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_30'>Elige solo una opcion<\/div><\/fieldset><div id=\"field_9_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_44'>Si tienes plan m\u00e9dico, \u00bfcu\u00e1l es?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_9_44' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfEst\u00e1s listo\/a para el cambio?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_36'><div class='gchoice gchoice_9_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='S\u00ed, totalmente'  id='choice_9_36_1'   aria-describedby=\"gfield_description_9_36\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_36_1' id='label_9_36_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed, totalmente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Estoy consider\u00e1ndolo'  id='choice_9_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_36_2' id='label_9_36_2' class='gform-field-label gform-field-label--type-inline'>Estoy consider\u00e1ndolo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Tengo dudas'  id='choice_9_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_36_3' id='label_9_36_3' class='gform-field-label gform-field-label--type-inline'>Tengo dudas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_36'>Elige solo una opcion<\/div><\/fieldset><div id=\"field_9_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_45'>\u00bfPor qu\u00e9 deseas unirte a Teen Challenge Puerto Rico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_9_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfTienes familia o amigos que te apoyan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_34'><div class='gchoice gchoice_9_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='S\u00ed, tengo apoyo'  id='choice_9_34_1'   aria-describedby=\"gfield_description_9_34\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_34_1' id='label_9_34_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed, tengo apoyo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Algo de apoyo'  id='choice_9_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_34_2' id='label_9_34_2' class='gform-field-label gform-field-label--type-inline'>Algo de apoyo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Me siento solo\/a'  id='choice_9_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_34_3' id='label_9_34_3' class='gform-field-label gform-field-label--type-inline'>Me siento solo\/a<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_34'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Teen Challenge Puerto Rico es un hogar Cristiano con departamento cl\u00ednico, \u00bfest\u00e1s de acuerdo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_37'><div class='gchoice gchoice_9_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='S\u00ed, estoy de acuerdo'  id='choice_9_37_1'   aria-describedby=\"gfield_description_9_37\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_37_1' id='label_9_37_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed, estoy de acuerdo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Tengo preguntas'  id='choice_9_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_37_2' id='label_9_37_2' class='gform-field-label gform-field-label--type-inline'>Tengo preguntas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='No estoy seguro\/a'  id='choice_9_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_37_3' id='label_9_37_3' class='gform-field-label gform-field-label--type-inline'>No estoy seguro\/a<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_37'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfCu\u00e1ndo estar\u00edas listo\/a para una entrevista?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_38'><div class='gchoice gchoice_9_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Lo antes posible'  id='choice_9_38_1'   aria-describedby=\"gfield_description_9_38\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_38_1' id='label_9_38_1' class='gform-field-label gform-field-label--type-inline'>Lo antes posible<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='En las pr\u00f3ximas semanas'  id='choice_9_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_38_2' id='label_9_38_2' class='gform-field-label gform-field-label--type-inline'>En las pr\u00f3ximas semanas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Necesito tiempo para considerarlo'  id='choice_9_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_38_3' id='label_9_38_3' class='gform-field-label gform-field-label--type-inline'>Necesito tiempo para considerarlo<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_38'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfTe interesa alguno de nuestros servicios espec\u00edficos?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_39'><div class='gchoice gchoice_9_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Servicio masculino'  id='choice_9_39_1'   aria-describedby=\"gfield_description_9_39\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_39_1' id='label_9_39_1' class='gform-field-label gform-field-label--type-inline'>Servicio masculino<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Servicio femenino'  id='choice_9_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_39_2' id='label_9_39_2' class='gform-field-label gform-field-label--type-inline'>Servicio femenino<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Centro de desintoxicaci\u00f3n'  id='choice_9_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_39_3' id='label_9_39_3' class='gform-field-label gform-field-label--type-inline'>Centro de desintoxicaci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_39_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.4' type='checkbox'  value='Todas las anteriores'  id='choice_9_39_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_39_4' id='label_9_39_4' class='gform-field-label gform-field-label--type-inline'>All of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_39'>Elige solo una opcion<\/div><\/fieldset><fieldset id=\"field_9_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00a1Gracias por compartir con nosotros! \u00bfC\u00f3mo te has sentido al completar este cuestionario?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_40'><div class='gchoice gchoice_9_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Esperanzado\/a'  id='choice_9_40_1'   aria-describedby=\"gfield_description_9_40\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_40_1' id='label_9_40_1' class='gform-field-label gform-field-label--type-inline'>Esperanzado\/a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Aliviado\/a'  id='choice_9_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_40_2' id='label_9_40_2' class='gform-field-label gform-field-label--type-inline'>Aliviado\/a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Ansioso\/a'  id='choice_9_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_40_3' id='label_9_40_3' class='gform-field-label gform-field-label--type-inline'>Ansioso\/a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Todas las anteriores'  id='choice_9_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_40_4' id='label_9_40_4' class='gform-field-label gform-field-label--type-inline'>All of the above<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_9_40'>Elige solo una opcion<\/div><\/fieldset><div id=\"field_9_14\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_14'>CAPTCHA<\/label><div id='input_9_14' class='ginput_container ginput_recaptcha' data-sitekey='6LfAN9EkAAAAAFlCoyvLWfYG2Z2AixQgdJw9XBkS'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='ENVIAR SOLICITUD'  \/> \n            <input type='hidden' class='gform_hidden' 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