Diagnosing a Problem

Needed to gamble with increasing amounts of money in order to achieve the desired excitement?*

Yes
No

Felt restless or irritable when attempting to cut down or stop gambling?*

Yes
No

Made repeated unsuccessful efforts to control, cut back, or stop gambling?*

Yes
No

Been preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)?*

Yes
No

Often gambled when feeling distressed (e.g., helpless, guilty, anxious, depressed)*

Yes
No

After losing money gambling, often returned another day to get even (“chasing” one’s losses)?*

Yes
No

Lied to conceal the extent of involvement with gambling?*

Yes
No

Jeopardized or lost a significant relationship, job, or education or career opportunity because of gambling?*

Yes
No

Relied on others to provide money to relieve desperate financial situations caused by gambling?*

Yes
No

Name

This field is for validation purposes and should be left unchanged.

In a 12 month period have you:

Contact

Supported in Part by: