Passport to Health Make a confidental enquiry

 

* Required Data

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

Please enter the following code in to the field: