Email Address
Title
Your first name(s)
Your last name
Date of Birth
Telephone Number
Gender Male Female
Race Identity Black White Mixed Race Other
Ethnic Group Afro Caribbean Asian Bangladeshi Black African Black Other Indian Mixed Pakistani White European White Other Other
Do you consider yourself to be disabled? Yes No
Are you registered disabled for employment purposes? Yes No
Have you ever spent more than you could afford gambling? Yes No
Have you gambled to try to win back gambling losses? Yes No
After a win do you have a strong urge to carry on gambling to win more? Yes No
Have you gambled to escape from problems, pressures or feelings (e.g. guilt, anxiety or depression)? Yes No
Have you had to gamble with more and more money in order to achieve the excitement, or other effects, you want from gambling? Yes No
Have you tried unsuccessfully to cut back or stop gambling? Yes No
If you have attempted to cut down or stop gambling, did it make you restless or irritable? Yes No
Have you ever gambled to try to get money with which to pay off debts or solve financial difficulties? Yes No
Have you had to borrow money to get out of a desperate financial situation caused by gambling? Yes No
Have you sold personal property or gone without something (e.g. food) to finance gambling? Yes No
Have you risked, or lost, a relationship or a home because of your gambling? Yes No
Have you missed work, school, appointments, opportunities or commitments due to gambling? Yes No
Have you planned ways to get money just to gamble with? Yes No
Have you spent time planning your next gambling session? Yes No
Have you relived, in your mind, past gambling experiences? Yes No
Do you spend most of the time you are awake either gambling or thinking about gambling? Yes No
Have you lied to anyone to hide the extent of your gambling? Yes No
Have you committed a dishonest act such as forgery, fraud or theft to raise cash to gamble with or pay off gambling debts? Yes No
Does gambling cause you to have problems sleeping? Yes No
Have you ever considered suicide as a result of your gambling? Yes No
Who suggested you applied to come to Gordon House? --Please select-- You Probation Officer Prison Visitor/Officer Hostel Worker Ex Gordon House Resident Other
Your Age Group --Please select-- under 17 17-20 21-25 26-35 36-59 60+
What is your main type of gambling? --Please select-- All Cash Fruit Machines Bingo Casino Card Games Casino Dice Games Casino Roulette Dogs Football Pools Fruit Machines Horses Internet Gambling Jackpot Machines Lottery Draw Other at Bookmakers Scratch Cards Spread Betting
What is your second type of gambling? --Please select-- All Cash Fruit Machines Bingo Casino Card Games Casino Dice Games Casino Roulette Dogs Football Pools Fruit Machines Horses Internet Gambling Jackpot Machines Lottery Draw Other at Bookmakers Scratch Cards Spread Betting
What is your third type of gambling? --Please select-- All Cash Fruit Machines Bingo Casino Card Games Casino Dice Games Casino Roulette Dogs Football Pools Fruit Machines Horses Internet Gambling Jackpot Machines Lottery Draw Other at Bookmakers Scratch Cards Spread Betting
Other Type of Gambling
What is your income? Annually Daily Monthly
What are your money losses?
What are your other losses (e.g. Partner, Family, Home, Car)?
Present accommodation --Please select-- Probation or Bail Hostel Other Hostel Board/Lodge B&B Parents Home Own Home Rented Homeless Prison Other
Please give a 'brief' history of your gambling saying who you started gambling with, when you feel it started to be a problem and how gambling has now affected your life and the lives of those around you. Please only give a summary here.
Please also give us any further information you feel will be useful in order to help Gordon House Association decide if we can help you.
Name of person helping you to fill in this application form (if anybody)
Relationship to person helping you to fill in this application form (if anybody)
