MCPCG

These questions will help you find out if you or someone you know has a problem with gambling.

Please take our confidential online survey
(Your email address will not be sent with the submission of this form):

Did you ever lose time from work due to gambling?	Yes No
Has gambling ever made your home life unhappy?	Yes No
Did gambling affect your reputation?	Yes No
Have you ever felt remorse after gambling?	Yes No
Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?	Yes No
Did gambling cause a decrease in your ambition or efficiency?	Yes No
After losing, did you feel you must return as soon as possible and win back your losses?	Yes No
After a win, did you have a strong urge to return and win more?	Yes No
Did you often gamble until your last dollar was gone?	Yes No
Did you ever borrow to finance your gambling?	Yes No
Have you ever sold anything to finance gambling?	Yes No
Were you reluctant to use "gambling money" for normal expenditures?	Yes No
Did gambling make you careless of the welfare of yourself and your family?	Yes No
Did you ever gamble longer than you had planned?	Yes No
Have you ever gambled to escape worry or trouble?	Yes No
Have you ever committed, or considered committing, an illegal act to finance gambling?	Yes No
Did gambling cause difficulty in sleeping?	Yes No
Do arguments, disappointments or frustrations create within you an urge to gamble?	Yes No
Did you ever have an urge to celebrate any good fortune by a few hours of gambling?	Yes No
Have you ever considered self destruction or suicide as a result of your gambling?	Yes No

It is very helpful for us to help you! Please answer the following confidential questions!

Preferred Type of Gambling:

Other Questions so we can help you!

Age:

Ethnicity:

Sex:Male Female