Questionnaire

If you have already visited the Casa, we would like to invite you to complete the following questionnaire.

Completion of this form need not involve any commitment on your part. At the very least we would be grateful if you would list a first name / last name and a country of residence. This would help us greatly in ascertaining figures of attendance. All other information is optional but it would be very helpful if you could tell us as much as possible about yourself and your Casa experience.

Completed questionnaires are used to give us continuous updates on people's experiences at the Casa.

Thank you and best wishes for all that you seek.

THE INFORMATION GATHERED WILL BE USED FOR RESEARCH TO SUPPORT THE WORK OF THE CASA. THIS WILL BE DONE ON AN ANONYMOUS BASIS.

	First Name:
	Last Name:

	Mailing Address:
	Country:
	Nationality:
	Language:

	Telephone:
	Email:

	Year of Birth:

	Male
	Female

	Occupation:


	If you do not want to receive newsletters from The Friends, please check here:
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When was your first visit to the Casa?
Month:
Year:

How many times have you visited the Casa?
How many weeks have you spent in total at the Casa?
How did you hear about the Casa?
	Friend:
	Web:
	Book:
	Media:
	Other:

Did you travel independently or as part of a group?
	Independently:
	Group:
	Both: (on different occasions)

Who was your group leader?
Other
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What was your reason for visiting the Casa? (If medical condition, be as specific as possible)


Did you have operations at the Casa. (Tick all that apply)
	None:
	Visible:
	Invisible:

Are you willing to share information about your experience at the Casa and any benefits you may have received?
	Yes:
	No:

Can this include any relevant medical records?
	Yes:
	No:

Are you willing to be contacted by us?
	Yes
	No
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	Are there any suggestions you would like to make to either The Casa or The Friends?


	How would you sum up your Casa experience?