LDH Gambling Screener

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2
Age
18-20
21-24
25-34
35-44
45-54
55-64
65+
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3
Zip Code* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please Select
Afghanistan
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Anguilla
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Mali
Malta
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Martinique
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Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
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South Ossetia
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Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
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Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
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United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Is this check-in for you or someone you care about?* This field is required.
It’s for me
It’s for someone I care about
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6
When you're feeling overwhelmed or stressed, what helps you cope?Select all that apply
I talk to someone I trust
I scroll on my phone
I exercise or go outside
I use substances (alcohol, drugs)
I’m not sure
Other
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8
Do you ever find yourself doing something over and over, even when it’s not making you feel better?* This field is required.
Yes
No
I’m not sure
9
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10
During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?* This field is required.
Yes
No
11
In the past 12 months, have you noticed them becoming restless, irritable, or anxious when trying to cut back or stop gambling?* This field is required.
Yes
No
12
During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?* This field is required.
Yes
No
13
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14
In the past 12 months, have they tried to hide how much they gamble from you or others?* This field is required.
Yes
No
15
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16
During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare?* This field is required.
Yes
No
17
In the past 12 months, have they had financial trouble from gambling that led them to ask you or others for help with living expenses?* This field is required.
Yes
No
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19
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