Do I have a problem with gambling? Client Registration Question Title * 1. Client Details First Name (optional) Last Name (optional) Street Address (optional) Suburb (optional) Question Title * 2. What is your current postcode? Question Title * 3. Date of Birth Date / Time Date Question Title * 4. What is your gender? Female Male Other (please specify) Question Title * 5. What is your country of birth? Australia Other (please specify) Question Title * 6. What is your preferred language? English Other (please specify) Question Title * 7. What is your ethnicity? Australian Other (please specify) Question Title * 8. Do you identify as an Australian or Torres Strait Islander? Yes (Aboriginal) Yes (Torres Strait Islander) Yes (both) No Question Title * 9. Referral Source - by Person (Select One ONLY) Gambling Helpline Other Helpline General Practitioner Community Health Service Mental Health Service Correctional/Legal Service Financial Counsellor Gamblers Anonymous Independent Gambling Authority Casino Staff Hotel Staff Club Staff Friend/Family Member Another Gambling Help Service Other (please specify) Question Title * 10. Referral Source - by other source (Select one only) Brochure Advertising Newspaper Article SA Problem Gambling Website Other website White Pages Yellow Pages Casino Information Hotel Information Club Information Social Media Other Media Other (please specify) Question Title * 11. What is your current work status? Employed Full Time Employed Part Time Casual Employment Self employed Unemployed Not in Paid Work: Home Duties Not in Paid Work: Student Not in Paid Work: Retired Not in Paid Work: Carer Incarcerated Unable to work (Disability) Not stated/inadequately Question Title * 12. What is your current martial status? Never Married Married Living with a partner Separated Widowed Divorced Other Not stated/inadequately Question Title * 13. Accommodation Setting (What best describes where you are currently living? Select one ONLY) Private residence - residence owned by client or client's family member Private Rental Residence Public Rental Residence (inc. Aboriginal housing) Boarding House Short-term crisis - emergency or transitional health or welfare facility Extended care - rehabilitation health or welfare facility Supported Living Unit/Facility Independent Living Unit/Facility Aboriginal Community - remote area Correctional Services Facility - client incarcerated Public place - no current accomodation not stated/inadequately described Question Title * 14. Contact Phone Number Next