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.

1. DATE: 1B. GENDER

MALE ( )

FEMALE ( )

4. ADDRESS:

7. REFRRAL SOURCE:

10. What is motivating your client to request

treatment?

13. Reason for residential treatment?

16. PREVIOUS TREATMENTS:

19. RELATIONSHIP STATUS:

2. NAME:

5. CITY:

POSTAL CODE:

8. REFERRAL SOURCE ADDRESS:

11. TYPE OF GAMBLING:

RESIDENTIAL PROGRAM REFERRAL INFORMATION

14. PHYSICAL CONDITION:

17. ANY MENTAL ILLNESSES? YES ( ) NO ( )

DIAGNOSIS:________________________________

DIAGNOSED BY: ____________________________

20. CHILDREN:

22. PLACE OF EMPLOYMENT:

PHONE: ( )

23. SOURCE OF INCOME:

25. Can client read/write English?

Yes ( ) Well ( ) O.K. ( ) No ( )

28.

26. ASSESSMENT DATE:

COUNSELLOR:

YES

NO 29. Does this person have a history of substance

abuse?

YES ( ) NO ( )

Does this person have suicidal ideation?

Does this person have a history of arson?

DRUG OF CHOICE:

Does this person have a history of violence?

3. PHONE: ( )

OK to call? YES ( ) NO ( )

OK to leave message? YES ( ) NO ( )

6. DATE OF BIRTH

DAY ________ MONTH _________ YEAR ________

9. REFERRAL SOURCE TELEPHONE #

12. GAMBLING HISTORY:

Date last gambled:

Years gambled:

15. ANY ALLERGIES:

15 B. ANY DIET RESTRICTIONS?

18. CHARGES PENDING: YES ( ) NO ( )

LIST CHARGES:

CURRENTLY ON PROBATION/ PAROLE:

YES ( ) NO ( )

21. PROBATION OFFICER:

PHONE:

24. LANGUAGES SPOKEN

27. CLIENT ETHNICITY

30. MEDICATIONS:

31. WHICH CYCLE OR DATE IS CLIENT SEEKING

ADMISSION FOR??

Problem Gambling Services

PROGRAM INFORMATION GUIDELINES

1.

2.

3.

4.

5.

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

6.

7. 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.

8. 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.

9. Television, newspapers, radio, videogames, internet access, MP3 players and all electronic devices are all prohibited during your stay here.

10. A mandatory appointment with our consulting Psychiatrist will be required while in the program.

11. 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

assigned to you for individual counseling sessions and to assist you during your treatment here.

12. 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.).

13. No drug or alcohol use is permitted while in program.

14. 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.

15. 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.

16. 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.

17. 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).

18. As per a scent-free policy within Hotel-Dieu Grace Healthcare, the use of perfumes, colognes, body sprays, etc. are prohibited.

19. Bring your valid Ontario Health Insurance Plan (OHIP) Card.

20. 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

__________________________________

Date

__________________________________

Client Signature

__________________________________

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 ____________________________________________________________________

Is patient on any medication(s)?

If yes, please specify dosage & duration below

Yes

No

Medication Dosage 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

OSAB KEY# (Office Use Only)

_________________________________

(Initials, DOB (yyyy/mm/dd) male – 1, female – 2)

PROBLEM GAMBLING SERVICES

CATALYST ADMISSION INFORMATION

CLIENT NAME: PRIMARY COUNSELLOR:

ADMISSION INFORMATION

Admission Date: dd ______ mm _______ yyyy _______ Client Type: ❒ Gambler ❒ Family Member/Friend

LEGAL STATUS

Treatment Mandated/ Required by:

❒ None ❒ Choice between treatment or jail ❒ Condition of Probation/Parole

❒ Child Welfare Authority ❒ Condition of employment ❒ Condition of school

❒ Condition of family ❒ Other ❒ Unknown

Legal Status

❒ No Problem ❒ Awaiting trial/sentencing ❒ Probation ❒ Parole ❒ 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 ❒ Some Primary School ❒ Primary School ❒ Some Secondary School

❒ Completed Secondary School ❒ Some Community College ❒ Completed College ❒Some University

❒ University Completed ❒ Unknown

INCOME SOURCE

❒ Disability Insurance

❒ Employment ❒ Employment Insc. (UI). ❒ Family Support.

❒ None ❒ ODSP (Ont. Disability)

❒ Ontario Works (Welfare) ❒ Other

❒ Other Insurance (excluding Emp. Insc) ❒ Retirement Income ❒ Unknown

PRESENTING ISSUES AT ADMISSION

❒ Gambling ❒ Gambling by other

❒ Addiction/Substance Abuse by Others

❒ Physical Abuse ❒ Mental/Emotional Abuse ❒ Sexual Abuse

❒ Financial

❒ Financial/Bankruptcy

❒ Legal

❒ Other Disorders: _______________________

PRESENTING PROBLEM SUBSTANCES (leave blank if none)

(Frequency of use in last 30 days)

1 st

____________________ ❒ did not use ❒ 1 – 3 times/mthly ❒ 1 – 2 times/week ❒ 3 – 6 times/week ❒ Daily ❒ Binge

2 nd

____________________❒ did not use ❒ 1 – 3 times/mthly ❒ 1 – 2 times/week ❒ 3 – 6 times/week ❒ Daily ❒ Binge

3 rd

____________________❒ did not use ❒ 1 – 3 times/mthly ❒ 1 – 2 times/week ❒ 3 – 6 times/week ❒ 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 ❒ Treatment Plan not established

❒ Declined treatment ❒ 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

2. Looking back now, for how many years has your gambling affected your life in negative ways?

Years ______ Months ______

3. Please indicate how long it has been since you last gambled:

(Record the number of years, months, weeks, or days)

Years _____ Months ______ Weeks ______ Days _______

4. 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

Less than once per month

1 –3 times a month

1 – 2 times weekly

3 – 6 times weekly

1.

2.

3.

4.

Played cards

Played Mahjong

Played live KENO

Played Roulette

5. Bets on horses, dogs, or other animals

6. Bets on sports (e.g.

Sports Select, bookie)

7. Bets on dice games

(e.g. craps)

8. Bought lottery tickets

(Pick 3, 6/49)

9. Bought scratch tickets

10. Bought tear-open tickets (Nevada)

11. Played Bingo

12. Played stock options/commodities market

13. Played VLT’s

14. Played slots or other non-VLT machines

15. Internet Gambling

16. Played pool/golf/or other game of skill

17. Sports pools

18. Betting on random events/informal bets

19. Other

5 (b) Please indicate the top three types of gambling problems, using the activity numbers in

Major __________ 1

St

other ___________ 2 nd

other ___________

Daily Unknown

6 (a) Please indicate how often you gambled in each of the following locations in the last 12 months.

Did not gamble

Less than once a month

1 – 3 times a month

1 – 2 times weekly

3 – 6 times weekly

1. In a commercial Casino

2. In a charity gaming club

3. In a bingo hall

4. At the race track

5. At an off-track betting location

6. On the Internet

7. On the television (bingo at home)

8. On the telephone (e.g. stocks, sports, betting)

9. Lottery kiosk/outlet

10. In family/friends setting

11. In a social club

12. In a restaurant/bar

13. In a school setting

14. In a work setting

15. In a senior’s center/home

16. In a custody/correctional facility

17. Somewhere else in the community

6 (b) Please indicate the top three locations for gambling, using the numbers in 6 (a)

Major ____________ 1 st

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: Pregnant:

❒ YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO

❒ Unknown ❒ Unknown ❒ Unknown

Non-Medical Intravenous Drug Use:

❒ Never injected ❒ Injected prior to one year ❒ Injected in past 12 months ❒ Unknown

Number of Overnight Hospitalizations in last 12 months for physical problems:

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 Within Lifetime: ❒ YES ❒ NO ❒ Unknown

Most Recent Diagnosis #1: _______________________ 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 ❒ Unknown Within lifetime: ❒ YES ❒ NO ❒ Unknown

Within last 12 months:

❒ YES ❒ NO ❒ Unknown

Prescribed Medication for a Mental Health Problem: Currently:

❒ YES ❒ NO ❒ Unknown

Within last 12 months:

❒ YES ❒ NO ❒ Unknown Within lifetime: ❒ YES ❒ NO ❒ 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

1

2

3

4

5

Preoccupation with Internet gaming.

Circle answer

YES NO

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

Tolerance: The need to spend increasing amounts of time engaged in Internet gaming.

YES NO

Unsuccessful attempts to control Internet gaming. YES NO

Continued excessive Internet gaming despite knowledge of negative psychosocial problems.

YES NO

6

7

Loss of interests, previous hobbies, and entertainment as a result of, and with the exception of, Internet gaming.

Use of Internet gaming to escape or relieve a dysphoric mood.

YES NO

YES NO

8

9

Has deceived family members, therapists, or others regarding the amount of Internet gaming.

Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of Internet gaming.

YES NO

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

2

3

4

5

6

7

8

9

TOTAL

SCORE

Needs to gamble with increasing amounts of money in order to achieve the desired excitement.

Is restless or irritable when attempting to cut down or stop gambling.

Has made repeated unsuccessful efforts to control, cut back, or stop gambling.

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).

Often gambles when feeling distressed (e.g. helpless, guilty, anxious, depressed).

After losing money gambling, often returns another day to get even (“chasing” one’s losses).

Lies to conceal the extent of involvement with gambling.

Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

Relies on others to provide money to relieve desperate financial situations caused by gambling.

Circle answer

YES

YES

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

NO

NO

PART B

1 The gambling behavior is not better explained by a manic episode.

Specify current severity:

YES NO

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

Rarely

2

Occasionally

3

Frequently

4

Often

5

Always

Question

1 How often do you find that you stay on-line longer than you intended?

2 How often do you neglect household chores to spend more time on-line?

3 How often do you prefer the excitement of the Internet to intimacy with your partner?

4 How often do you form new relationships with fellow on-line users?

5 How often do others in your life complain to you about the amount of time you spend on-line?

6 How often do your grades or school work suffer because of the amount of time you spend on-line?

7 How often do you check your e-mail before something else that you need to do?

8 How often does your job performance or productivity suffer because of the Internet?

9 How often do you become defensive or secretive when anyone asks you what you do on-line?

10 How often do you block out disturbing thoughts about your life with soothing thoughts of the Internet?

11 How often do you find yourself anticipating when you will go on-line again?

12 How often do you fear that life without the Internet would be boring, empty, and joyless?

13 How often do you snap, yell, or act annoyed if someone bothers you while you are on-line?

14 How often do you lose sleep due to late-night log-ins?

15 How often do you feel preoccupied with the Internet when off-line, or fantasize about being on-line?

16 How often do you find yourself saying “just a few more minutes” when on-line?

17 How often do you try to cut down the amount of time you spend on-line and fail?

Scale

0 1 2 3 4 5

18 How often do you try to hide how long you’ve been on-line?

19 How often do you choose to spend more time on-line over going out with others?

20 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

Clinical Instructions:

Tally the responses of the client and share the following criteria.

Normal Range: 0-30 points

Mild: 31-49 points

Moderate:

Severe:

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)

Shade circles like this:

Not like this:

FOR OFFICE USE ONLY: FAX: 519-254-0093

DATIS KEY:

DART:

1. In the past 12 months, what was the largest amount of money you

$

.00

have gambled with on any one day?

(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?

7. In the past 12 months, have people criticized your gambling?

Yes No

Yes No

©1986 South Oaks Foundation, Inc. www.longislandhome.org

FORM B-2:

(SOGS con’t)

FOR OFFICE USE ONLY: FAX: 519-254-0093

DATIS KEY:

Shade circles like this:

Not like this:

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?

10. In the past 12 months, have you ever hidden betting slips, lottery tickets,

Yes No gambling money, IOUs, or other signs of betting or gambling from your spouse, children or other important people in your life?

11. In the past 12 months, have you ever argued with people you live with over how you handle money?

Yes No

Yes No

Yes No

12. (If you answered "yes" to question #11) Have money arguments ever centered on your gambling?

Yes No

13. In the past 12 months, have you ever borrowed from someone and not paid them back as a result of your gambling?

Yes No

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) a) from house hold money……………………………………………………......

Yes No 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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