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I need HELP now
I'm concerned
about MY gambling
I'm worried about SOMEONE'S gambling
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Confidential Question
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Personal Information
First Name:*
Last Name:*
Email Address:*
Phone:
Address:
Suburb:
Town/City:
Ethnicity:
Date of Birth:
Gender:*
Male
Female
What gambling applies to you? Check all that apply.
Pub Pokies
Club Pokies
TAB
Sports
Housie
Cards
Other
Choose Yes or No as appropriate.
Do you feel you currently have a problem with gambling?*
Yes
No
Have you ever felt the need to bet more and more money?*
Yes
No
Have you ever lied about how much you gambled?*
Yes
No
Do you feel you have ever had a problem with gambling?*
Yes
No
If you answered yes to any of the above, what would help?
I would like some information
I would like to talk about it in confidence with someone.
I would like some support.
Nothing at this stage
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