Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1. Is your time and thoughts always preoccupied by gambling activities? *YesNo2. Do you gamble to relieve a bad mood or escape problems? *YesNo3. Do you increase amount of money to gamble with in order to win what you’ve lost previously? *YesNo4. Do you chase after your losses? *YesNo5. Have you ever lied to anyone about your gambling behaviour? *YesNo6. Has your gambling behaviour caused damaging consequences in your family, work/school or social life? *YesNo7. Have you unsuccessfully tried to stop your gambling behaviour? *YesNo8. Do you feel restless and irritable when you try to cut or stop your gambling behaviour? *YesNo9. Have you borrowed or asked others for money to gamble with? *YesNo10. Have you ever done something illegal to get money to gamble or pay gambling debts? *YesNoDid you answer YES to 5 or more questions?YesNoIf you have answered "YES" to 5 or more questions, it could be that you have a GAMBLING PROBLEM.NameFirstLastPhone+27 73 555 5555Preferred Time of Contact08:00 - 12:0013:00 - 18:00Email AddressEmailConfirm EmailProvince *Eastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern CapeAge Group *18 - 2526 - 3738 - 5051 and aboveRace BlackWhiteIndianColouredWebsiteSubmit