problem gambling residential treatment referral package please

problem gambling residential treatment referral package please
PROBLEM GAMBLING RESIDENTIAL TREATMENT REFERRAL PACKAGE
PLEASE ENSURE THAT ALL OF THE REQUIRED FORMS ARE COMPLETED
FULLY!
FAX COMPLETED PACKAGE TO 519 254-0093
PLEASE NOTE THAT OUR PACKAGE NOW INCLUDES 2 SCREENING
TOOLS FOR INTERNET GAMING DISORDER AND INTERNET
ADDICTION AS OUR AGENCY HAS NOTICED SOME COMORBIDITY
WITH OUR CLIENTS. THE TOOLS ARE VERY EASY TO ADMINISTER
AND MAY PROVIDE YOU WITH SOME VALUABLE INFORMATION
REGARDING YOUR CLIENT’S USE OF DIGITAL TECHNOLOGY.
THE FOLLOWING FORMS SHOULD BE INCLUDED:
1. HDGH CONSENT FORM *signed by client
2. RESIDENTIAL PROGRAM REFERRAL INFORMATION FORM
3. CATALYST ADMISSION FORM
4. SOUTH OAKS GAMBLING SCREEN (SOGS)
5. DSM 5 GAMBLING DISORDER
6. DSM 5 INTERNET GAMING DISORDER
7. INTERNET ADDICTION TEST (IAT)
8. MEDICAL CLEARANCE FORM* to be given to client for completion by family Dr.
9. BASIS 32
10. RESIDENTIAL PROGRAM GUIDELINES 2015
11. FAMILY PROGRAM INFORMATION
If you have any questions please contact the Program Secretary (Laurie/Julie) for assistance at
519 254-2112 or 519 257-5111 ext 76990.
RESIDENTIAL PROGRAM REFERRAL INFORMATION
1. DATE:
1B. GENDER
MALE (
)
FEMALE (
)
2. NAME:
4. ADDRESS:
5. CITY:
3. PHONE: (
)
OK to call?
OK to leave message?
6. DATE OF BIRTH
7. REFRRAL SOURCE:
POSTAL CODE:
8. REFERRAL SOURCE ADDRESS:
DAY ________ MONTH _________ YEAR ________
9. REFERRAL SOURCE TELEPHONE #
11. TYPE OF GAMBLING:
12. GAMBLING HISTORY:
Date last gambled:
10. What is motivating your client to request
treatment?
YES (
YES (
)
)
NO (
NO (
)
)
Years gambled:
13. Reason for residential treatment?
14. PHYSICAL CONDITION:
15. ANY ALLERGIES:
15 B. ANY DIET RESTRICTIONS?
16. PREVIOUS TREATMENTS:
17. ANY MENTAL ILLNESSES?
YES (
) NO ( )
18. CHARGES PENDING:
LIST CHARGES:
YES (
) NO (
)
DIAGNOSIS:________________________________
DIAGNOSED BY: ____________________________
19. RELATIONSHIP STATUS:
20. CHILDREN:
CURRENTLY ON PROBATION/ PAROLE:
YES (
)
NO (
)
21. PROBATION OFFICER:
22. PLACE OF EMPLOYMENT:
23. SOURCE OF INCOME:
PHONE:
24. LANGUAGES SPOKEN
PHONE: (
)
25. Can client read/write English?
26. ASSESSMENT DATE:
27. CLIENT ETHNICITY
Yes (
28.
) Well (
) O.K. (
Does this person have suicidal ideation?
Does this person have a history of arson?
Does this person have a history of
violence?
) No (
YES
)
NO
COUNSELLOR:
29. Does this person have a history of substance
abuse?
YES (
) NO (
)
DRUG OF CHOICE:
30. MEDICATIONS:
31. WHICH CYCLE OR DATE IS CLIENT SEEKING
ADMISSION FOR??
Problem Gambling Services
PROGRAM INFORMATION GUIDELINES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Prescriptions need to come in their original bottle or compliance packages from the
pharmacy. Homemade Dosett or pill organizers will not be permitted. Any
medication not provided in this form will not be administered. Please ensure that
you bring a three (3) week supply of your medications.
Any over the counter medication, including vitamins, Tylenol, etc. must be brought
in a new, unopened container; otherwise, this medication will not be permitted. We
do not carry any stock medication on site. All medication will need to be brought by
the client.
Clients must ensure that all medical and dental needs have been taken care of before
attending treatment.
Cell phones are not permitted to be used during the 3 week program. Cell phones
will be turned into the Attendant upon intake and returned to the client at discharge.
Clients are asked to bring calling cards to be utilized during phone time. Client’s are
permitted half-hour phone time per day.
Food, laundry service and linens are provided. Please ensure that staff is aware of all
diet restrictions before attending the program. Bring your own toiletries. Feel free to
bring anything else that will make you feel more comfortable. E.g.; pop, snacks,
frozen meals.
You will be sleeping in a private bedroom with an attached bathroom. A closet with
a lock is also provided for your personal belongings. Clients are required to share one
of two, private shower stalls. Shower shoes are also required, and a bath robe is
recommended.
You will be required to attend fitness sessions twice per week with a personal trainer.
Bring suitable work out clothing and running shoes. Fitness will be modified to
ensure safety. Please let intake worker and fitness instructor know about any
physical limitations.
No gambling paraphernalia is allowed, including and not limited to cards, lottery,
scratch, or Proline tickets. Any of these items will be confiscated and disposed of if
brought to the program.
Television, newspapers, radio, videogames, internet access, MP3 players and all
electronic devices are all prohibited during your stay here.
A mandatory appointment with our consulting Psychiatrist will be required while in
the program.
Clients will be in program for approximately 85% of their time here, often from 8:00
a.m. to 8:00 p.m. This is mainly group work; however, a primary counselor will be
1
12.
13.
14.
15.
16.
17.
18.
19.
20.
assigned to you for individual counseling sessions and to assist you during your
treatment here.
The first week of program is closed and residents are not allowed to leave the
building. Please bring enough supplies to cover the entire three week period of your
stay (such as toiletries, cigarettes, and medications etc.).
No drug or alcohol use is permitted while in program.
Dress is to be appropriate, clean, and free of any sports teams or gambling
advertisements. Modest and good taste will guide the choice of clothing at all times.
Clothing that works well for the beach, yard work, dance clubs, and sports contests
may not be appropriate for our residential program. Clothing that reveals too much
cleavage, your back, your chest, your feet, your stomach or your underwear is not
appropriate. All clothing will be placed in a dryer on high heat upon arrival. Please
do not bring any clothing that you would not like to be placed in a dryer.
Casual shoes are appropriate for the daily program. No bedroom slippers are to be
worn during the program sessions. Clean socks are required at all times in the shared
living area.
It is strongly advised that you do not bring large amounts of cash, jewelry, or other
valuable items. If you choose to bring some spending money, we advise that you
limit it to $100 or less.
Permission to leave the building takes place after the first week only, and then will
be done with consent from the primary counsellor. All residents leaving the building
with permissions must use the ‘buddy system’. Residents are not allowed to leave
the building alone at any time. WHILE THE CLIENTS ARE AWAY FROM
THE BUILDING ON THE BUDDY SYSTEM, THEY MUST STAY IN CLOSE
PROXIMITY OF EACH OTHER (IE. WITHIN ARMS LENGTH, DURING
THE ENTIRE OUTING).
As per a scent-free policy within Hotel-Dieu Grace Healthcare, the use of perfumes,
colognes, body sprays, etc. are prohibited.
Bring your valid Ontario Health Insurance Plan (OHIP) Card.
If you get lost or require any assistance upon your arrival, please call 519-257-5111
Extension 76990 to reach staff in the Residential Treatment Program. Clients will be
discharged from the program at 12:30 p.m. on the last Friday of the 3-week program.
__________________________________
Referral Agent Signature
__________________________________
Client Signature
__________________________________
Date
__________________________________
Date
2
Problem Gambling Services
1453 Prince Rd. Windsor, Ontario N9C 3Z4
Residential Program Medical Clearance Form
Patient Name: ______________________________
O.H.C. #: ______________________________
Is patient free from serious communicable disease?
Yes

No

If not, please specify ____________________________________________________________________
Yes
Is patient on any medication(s)?
If yes, please specify dosage & duration below
Medication
Dosage

No

Duration
Does patient have any allergies?
Yes

No

If so, please specify_____________________________________________________________________
_____________________________________________________________________________________
Does this patient have any other pre-existing medical conditions that may inhibit their participation in
this program? Please list all below.
_____________________________________________________________________________________
_____________________________________________________________________________________
Is this patient able to:
Sit in a chair for up to 2 hours?
Participate in moderate exercise classes 2x per week?
Yes
Yes


No
No


Is patient medically fit to attend the 21-day residential program at HDGH Problem Gambling Services?
Yes

No

If patient is not cleared for participation in program, please give reason: ________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________
Physician Signature
____________________________________________
Physician Address
Date: ____________________
Physician Phone Number: _______________________
Please fax this form to Problem Gambling Services – 519-254-0093
PROBLEM GAMBLING SERVICES
CATALYST ADMISSION INFORMATION
OSAB KEY# (Office Use Only)
_________________________________
CLIENT NAME:
PRIMARY COUNSELLOR:
(Initials, DOB (yyyy/mm/dd) male – 1, female – 2)
ADMISSION INFORMATION
Client Type: ❒ Gambler ❒ Family Member/Friend
Admission Date: dd ______ mm _______ yyyy _______
LEGAL STATUS
Treatment Mandated/ Required by:
❒ None
❒ Child Welfare Authority
❒ Condition of family
Legal Status
❒ No Problem
❒ Choice between treatment or jail
❒ Condition of employment
❒ Other
❒ Awaiting trial/sentencing
❒ Probation ❒ Parole
❒ Condition of Probation/Parole
❒ Condition of school
❒ Unknown
❒ Incarcerated
❒ Other
❒ Unknown
Young Offender? ❒ Yes ❒ No ❒ Unknown ❒ Not Applicable
Probation:
Start date: dd______mm _______ yyyy _______ End date: dd_______ mm _____ yyyy ______
RELATIONSHIP STATUS
❒ Married/Partnered/Common Law
❒Single (Never Married)
❒Widow/Widower
❒Separated/Divorced ❒ Unknown
EMPLOYMENT STATUS
❒ Employed/Full Time, includes self employed ❒Employed Part-time ❒Unemployed (Looking for Work)
❒ Student/Retraining
❒ Disabled (Not Working)
❒ Not in Working Force (e.g. Homemaker) ❒ Retired ❒ Unknown
Employer: __________________________________
OK to Call:
YES ❒
NO ❒
EDUCATION
❒ No Formal Schooling
❒ Completed Secondary School
❒ University Completed
❒ Some Primary School
❒ Some Community College
❒ Unknown
❒ Primary School
❒ Completed College
❒ Some Secondary School
❒Some University
INCOME SOURCE
❒ Disability Insurance
❒ Employment
❒ None
❒ ODSP (Ont. Disability)
❒ Other Insurance (excluding Emp. Insc)
❒ Employment Insc. (UI).
❒ Family Support.
❒ Ontario Works (Welfare)
❒ Retirement Income
❒ Other
❒ Unknown
PRESENTING ISSUES AT ADMISSION
❒ Gambling
❒ Gambling by other
❒ Addiction/Substance Abuse by Others
❒ Physical Abuse ❒ Mental/Emotional Abuse
❒ Financial
❒ Financial/Bankruptcy
❒ Legal
❒ Other Disorders: _______________________
❒ Sexual Abuse
PRESENTING PROBLEM SUBSTANCES (leave blank if none)
(Frequency of use in last 30 days)
1st ____________________ ❒ did not use
2nd ____________________❒ did not use
3rd ____________________❒ did not use
❒ 1 – 3 times/mthly ❒ 1 – 2 times/week ❒ 3 – 6 times/week
❒ 1 – 3 times/mthly ❒ 1 – 2 times/week ❒ 3 – 6 times/week
❒ 1 – 3 times/mthly ❒ 1 – 2 times/week ❒ 3 – 6 times/week
❒ Daily ❒ Binge
❒ Daily ❒ Binge
❒ Daily ❒ Binge
SUBSTANCES USED IN LAST 12 MONTHS (leave blank if none)
❒ None
❒ Benzodiazepines
❒ Glue/Inhalant
❒ Script. opiates
❒ Unknown
❒ Cannabis
❒ Hallucinogens
❒ Tobacco
❒ Alcohol
❒ Cocaine
❒ Heroin/Opium
❒ Other ________________
❒ Amphetamines
❒ Crack
❒ Over the counter codeine
❒ Barbiturates
❒ Ecstasy
❒ Other/Psycho – Active
GAMBLING
Treatment Plan: ❒ Treated within this agency
❒ Declined treatment
❒ Declined treatment
❒ Treatment Plan not established
❒ Referred to a designated gambling agency
Gambling Activities Engaged in Past 12 months:
❒ Bingo
❒ Slot machines
❒ Gaming machines (other than slots)
❒ Casino -Card/table games
❒ Non-Casino Card/Table Games
❒ Horse races
❒ Sports betting
❒ Lottery tickets
❒ Instant win/ scratch tickets
❒ Internet gambling
❒ Gambling with stock market/real – estate
❒ Betting on games of skill
❒ Betting on outcome of events
❒ Other _______________________
❒ None
❒ Unknown / Data unavailable
OSAB Required Gambling Data Form
1.
Are you seeking help for:
❒ Your own difficulties related to a family member/significant other’s gambling. STOP HERE
❒ Your own gambling problem. PLEASE CONTINUE
❒ Both: PLEASE CONTINUE
Looking back now, for how many years has your gambling affected your life in negative ways?
2.
Years ______
3.
Months ______
Please indicate how long it has been since you last gambled:
(Record the number of years, months, weeks, or days)
Years _____
4.
Months ______ Weeks ______ Days _______
Please indicate whether:
❒
You came to this agency specifically for gambling treatment
❒
Your gambling problem surfaced in the course of other treatment
5(a) Please indicate how often you engaged in each of the following gambling activities in the past 12
months:
Did not gamble in the past 12 months: ❒
Did not
gamble
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Less than
once per
month
1 –3 times a
month
1 – 2 times
weekly
Played cards
Played Mahjong
Played live KENO
Played Roulette
Bets on horses, dogs, or
other animals
Bets on sports (e.g.
Sports Select, bookie)
Bets on dice games
(e.g. craps)
Bought lottery tickets
(Pick 3, 6/49)
Bought scratch tickets
Bought tear-open
tickets (Nevada)
Played Bingo
Played stock
options/commodities
market
Played VLT’s
Played slots or other
non-VLT machines
Internet Gambling
Played pool/golf/or
other game of skill
Sports pools
Betting on random
events/informal bets
Other
5 (b) Please indicate the top three types of gambling problems, using the activity numbers in
Major __________
1St other ___________ 2nd other ___________
3 – 6 times
weekly
Daily
Unknown
6 (a) Please indicate how often you gambled in each of the following locations in the last 12 months.
Did not
gamble
1.
2.
3.
4.
In a commercial Casino
In a charity gaming club
In a bingo hall
At the race track
5.
At an off-track betting
location
On the Internet
On the television (bingo
at home)
On the telephone (e.g.
stocks, sports, betting)
Lottery kiosk/outlet
In family/friends setting
In a social club
In a restaurant/bar
In a school setting
In a work setting
In a senior’s center/home
In a custody/correctional
facility
Somewhere else in the
community
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Less than
once a
month
1 – 3 times a
month
1 – 2 times
weekly
3 – 6 times
weekly
6 (b) Please indicate the top three locations for gambling, using the numbers in 6 (a)
Major ____________
1st other ______________
2nd other __________
7. Thinking about the times you gambled in the past 12 months, what percent were:
(Numbers should add up to 100%; leading zeros not necessary)
(a) in Ontario _________ % (b) in another province _______% (c) Outside of Canada ______%
Daily
Unknown
HEALTH STATUS
Visual Impairment:
Hearing Impairment:
Mobility/Physically Impairment:
❒ YES
❒ YES
❒ YES
❒ NO
❒ Unknown
❒ NO
❒ Unknown
Pregnant:
❒ NO
❒ YES
❒ NO
❒ Unknown
Non-Medical Intravenous Drug Use:
❒
Never injected
❒ Injected prior to one year
❒ Injected in past 12 months
Number of Overnight Hospitalizations in last 12 months
for physical problems:
❒ Unknown
Reason for most recent Hospitalization:
Diagnosed with a Mental Health problem by a qualified Mental Health Professional:
Within the last 12 months:
❒ YES ❒ NO ❒ Unknown
Most Recent Diagnosis #1: _______________________
Within Lifetime:
❒ YES ❒ NO
❒ Unknown
Most Recent Diagnosis #2: __________________________
Hospitalized for a Mental Health problem?
Within the last 12 months: ❒ YES
❒ NO
❒ Unknown
Within lifetime: ❒ YES
❒ NO
❒ Unknown
Received Treatment for a Mental Health, Emotional, Behavioural or Psychological problem from a Community Mental Health
Program or Professional:
Currently:
❒ YES
❒ NO
Within last 12 months: ❒ YES
❒ Unknown
❒ NO
Within lifetime: ❒ YES
❒ YES ❒ NO
❒ Unknown
❒ Unknown
Prescribed Medication for a Mental Health Problem:
Within last 12 months:
❒ NO
❒ Unknown
Currently:
❒ YES
❒ NO
Within lifetime: ❒ YES
❒ NO
❒ Unknown
❒
Unknown
Health Conditions/Problems: (circle applicable): Allergies, Blood Pressure, Cancer, Chronic Pain, Diabetes, Eating Disorder,
HIV/AIDS, Heart Disease, Lice/Scabies, Liver Disease, Menstrual/Menopausal/ Pancreatitis, Respiratory, STD, Stomach, Thyroid,
Tuberculosis
Provider of Primary Health Care: _________________________________________________________________
Prescribed Drugs:
Methadone: ❒ YES ❒ NO
❒ Unknown
Drugs Currently Prescribed: ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
CATALYST ADMISSION INFORMATION revised for HDGH October 1, 2013
DSM-5 Criteria: Internet Gaming Disorder
Persistent and recurrent Internet Gaming behavior leading to clinically significant impairment or
distress as indicated by five (or more) of the following in a 12-month period:
PART A
Circle answer
1
Preoccupation with Internet gaming.
YES
NO
2
Withdrawal symptoms when Internet gaming is taken away (these symptoms are
typically described as irritability, anxiety, sadness, but no physical signs of
pharmacological withdrawal).
YES
NO
3
Tolerance: The need to spend increasing amounts of time engaged in Internet gaming.
YES
NO
4
Unsuccessful attempts to control Internet gaming.
YES
NO
5
Continued excessive Internet gaming despite knowledge of negative psychosocial
problems.
YES
NO
6
Loss of interests, previous hobbies, and entertainment as a result of, and with the
exception of, Internet gaming.
YES
NO
7
Use of Internet gaming to escape or relieve a dysphoric mood.
YES
NO
8
Has deceived family members, therapists, or others regarding the amount of Internet
gaming.
YES
NO
9
Has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of Internet gaming.
YES
NO
TOTAL
SCORE
From the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition - Section III
DSM-5 Criteria: Gambling Disorder
Persistent and recurrent problematic gambling behavior leading to clinically significant
impairment or distress, as indicated by the individual exhibiting four (or more) of the
following in a 12-month period:
PART A
1
Circle answer
Needs to gamble with increasing amounts of money in order to achieve the desired
excitement.
YES
NO
2
Is restless or irritable when attempting to cut down or stop gambling.
YES
NO
3
Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
YES
NO
4
Is often preoccupied with gambling (e.g. having persistent thoughts of reliving past
gambling experiences, handicapping or planning the next venture, thinking of ways to
get money with which to gamble).
YES
NO
5
Often gambles when feeling distressed (e.g. helpless, guilty, anxious, depressed).
YES
NO
6
After losing money gambling, often returns another day to get even (“chasing” one’s
losses).
YES
NO
7
Lies to conceal the extent of involvement with gambling.
YES
NO
8
Has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of gambling.
YES
NO
Relies on others to provide money to relieve desperate financial situations caused by
gambling.
YES
NO
9
TOTAL
SCORE
PART B
1
The gambling behavior is not better explained by a manic episode.
YES
NO
Specify current severity:
Mild: 4–5 criteria met.
Moderate: 6–7 criteria met.
Severe: 8–9 criteria met.
Specify if:
Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of
gambling disorder for at least several months.
Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years.
Specify if:
In early remission: After full criteria for gambling disorder were previously met, none of the criteria for
gambling disorder have been met for at least 3 months but for less than 12 months.
In sustained remission: After full criteria for gambling disorder were previously met, none of the criteria for
gambling disorder have been met during a period of 12 months or longer.
From the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (section 312.31).
The Internet Addiction Test (IAT)
Internet Addiction Test (IAT) is a reliable and valid measure of addictive use of Internet, developed by Dr.
Kimberly Young. It consists of 20 items that measures mild, moderate and severe level of Internet Addiction.
Instructions to Respondent:
Below is a list of problems and areas of life functioning in which some people experience difficulties.
Using the scale below, fill in the box with the answer that best describes how much difficulty you have
been having in each area. Please do not leave any questions blank. If there is an area that you consider to
be inapplicable, indicate that it is 0 = Does Not Apply.
0
Does Not Apply
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
1
Rarely
2
Occasionally
3
Frequently
4
Often
Question
How often do you find that you stay on-line longer than you intended?
How often do you neglect household chores to spend more time on-line?
How often do you prefer the excitement of the Internet to intimacy with your
partner?
How often do you form new relationships with fellow on-line users?
How often do others in your life complain to you about the amount of time you
spend on-line?
How often do your grades or school work suffer because of the amount of time you
spend on-line?
How often do you check your e-mail before something else that you need to do?
How often does your job performance or productivity suffer because of the Internet?
How often do you become defensive or secretive when anyone asks you what you do
on-line?
How often do you block out disturbing thoughts about your life with soothing
thoughts of the Internet?
How often do you find yourself anticipating when you will go on-line again?
How often do you fear that life without the Internet would be boring, empty, and
joyless?
How often do you snap, yell, or act annoyed if someone bothers you while you are
on-line?
How often do you lose sleep due to late-night log-ins?
How often do you feel preoccupied with the Internet when off-line, or fantasize
about being on-line?
How often do you find yourself saying “just a few more minutes” when on-line?
How often do you try to cut down the amount of time you spend on-line and fail?
How often do you try to hide how long you’ve been on-line?
How often do you choose to spend more time on-line over going out with others?
How often do you feel depressed, moody, or nervous when you are off-line, which
goes away once you are back on-line?
Reprinted for use by permission of Dr. Kimberly Young, Psychologist
© Dr. Kimberly Young, The Center for Internet Addiction, and Netaddiction.com
5
Always
0
1
Scale
2 3
4
5
Clinical Instructions:
Tally the responses of the client and share the following criteria.
Normal Range:
Mild:
Moderate:
Severe:
0-30 points
31-49 points
50-79 points
80-100 points
Reprinted for use by permission of Dr. Kimberly Young, Psychologist
© Dr. Kimberly Young, The Center for Internet Addiction, and Netaddiction.com
PROBLEM GAMBLING SERIVCES
1453 Prince Road – Emara Building
Windsor, Ontario N9C 3Z4
Phone #: 519-254-2112
Fax: 519-254-0093
Email:[email protected]
FAMILY AND FRIEND PROGRAM
Hotel-Dieu Grace Healthcare Problem Gambling Services believes that disordered gambling is an illness
that affects not only the person gambling, but also those who are involved in a significant relationship
with the gambler.
Since we know that living or being involved with a problem gambler creates stress, mistrust and
emotional pain, it can be helpful to family members and friends if they can receive some education
about disordered gambling and meet others who are experiencing similar difficulties.
Hotel-Dieu Grace Healthcare Problem Gambling Services offers a program for family and/or friends of
the gambler enrolled in our residential program. This one day program offers information regarding
disordered gambling and the effects upon the family member and friends.
The program is offered the second Saturday of the residential program. It runs from 9:30 a.m. until 4:30
p.m. and lunch is provided.
We strongly recommend that you invite your family and/or friends to attend this program. When you
arrive for your residential program, you will have a few days to provide our staff with names and e-mail
addresses or mailing addresses so we can send out an invitation(s) on your behalf.
Adolescents between the ages of 13 and 17 are welcome to attend when accompanied by an adult.
Children under the age of 13 are not permitted to attend.
FORM B-1: SOUTH OAKS GAMBLING SCREEN (SOGS)
FOR OFFICE USE ONLY:
Shade circles like this:
FAX: 519-254-0093
DATIS KEY:
DART:
Not like this:
1. In the past 12 months, what was the largest amount of money you
have gambled with on any one day?
.00
$
(TO THE NEAREST DOLLAR
WITHOUT A DECIMAL PLACE,
WITHOUT LEADING ZEROS)
2. Check which of the following people in your life has (or had) a gambling problem:
(mark all that apply)
Father
Mother
Brother/Sister
Grandparent
My child(ren)
My spouse/partner
Another relative
A Friend or someone important in my life
3. Over the past 12 months when you have gambled, how often did you go back another day to win
back money you have lost?
Never
Some of the time (less than half of time I lost)
Most of the time
Every time that I lose
4. In the past 12 months, have you ever claimed to be winning money gambling but weren’t really?
In fact, you lost.
Never (or never gamble)
Yes, less than half of time I lost
Yes, most of the time
5. In the past 12 months, do you feel you have ever has a problem with gambling?
No
Yes, some months ago
Yes
6. In the past 12 months, did you ever gamble more than you intended to?
Yes
No
7. In the past 12 months, have people criticized your gambling?
Yes
No
©1986 South Oaks Foundation, Inc.
www.longislandhome.org
FORM B-2: (SOGS con’t)
FOR OFFICE USE ONLY:
Shade circles like this:
Not like this:
FAX: 519-254-0093
DATIS KEY:
DART:
8. In the past 12 months, have you ever felt guilty about the way you gamble, or
what happens when you gamble?
Yes
No
9. In the past 12 months, have you ever felt like you would like to stop gambling
but didn’t think you could?
Yes
No
10. In the past 12 months, have you ever hidden betting slips, lottery tickets,
gambling money, IOUs, or other signs of betting or gambling from your spouse,
children or other important people in your life?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
11. In the past 12 months, have you ever argued with people you live with over how
you handle money?
12. (If you answered "yes" to question #11) Have money arguments ever centered on
your gambling?
13. In the past 12 months, have you ever borrowed from someone and not paid them
back as a result of your gambling?
14. In the past 12 months, have you ever lost time from work (or school) due to
gambling?
15. If you borrowed money to gamble or pay gambling debts, in the past 12 months, who or where
did you borrow from? (check yes or no for each)
Yes
No
a) from house hold money……………………………………………………......
b) from your spouse/partner..…………………………………………………….
c) from other relatives or in-laws..…………………………………………….....
d) from banks, loan companies, or credit unions…………………………………
e) from credit cards……..……………………………………………………......
f) from loan sharks……………....…………………………………………….....
g) you cashed in stocks, bonds, or other securities………….……………………
h) you sold personal or family..………………………………………………......
i) you borrowed on your chequing account (passed bad cheques)...………….....
j) you have (had) a line of credit with a bookie.…………………………………
k) you have (had) a credit line with a casino…………………………………......
©1986 South Oaks Foundation, Inc.
www.longislandhome.org
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