Online Gambling Questionnaire

Welcome to our Online Gambling Questionnaire — the fastest way to get answers about treatment options and procedures for gambling addiction at our clinic. Start here to gain insight and take the first step toward recovery.

Gambling Questionnaire

First Name

Country

Date of Birth

Phone Number

When did gambling first become a problem?

What type of gambling do you play the most (slots, roulette, sports betting, other)?

What’s the longest time you’ve spent gambling in one session?

How many days in a row have you spent gambling? What’s the longest period you’ve stayed away from it?

What’s the largest amount you’ve won and the largest amount you’ve lost?

Have you tried treatment before? If so, where, how, and what were the results?

Do you have any health conditions (allergies, seizures, fainting, hallucinations, depression)?

Have you tried treatment before? If so, where, how, and what were the results?

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