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<title>Potential Gambling Problem Survey</title>
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    <h2 align="left">Potential Gambling Problem Survey   </h2>
    <h3>Gambling Addiction Treatment is Available at The Center.</h3>
    <p>This questionnaire is used by Gamblers Anonymous to help determine if a person has a problem with gambling. According to their material, most compulsive gamblers will answer yes to at least seven of the following questions. (Be aware, however, that even if you answer yes to only four or three or two you may not be &quot;right&quot; in God's sight. God may have a different standard for you than Gamblers Anonymous. Each person has a unique, individual relationship with God, and only he knows our heart and our weaknesses.) </p>
    <p>If you already know you have a gambling addiction, we encourage you to contact The Center at 1-888-771-5166. </p>
    <form method="post" action="http://www.aplaceofhope.com/cgi-bin/ttg.cgi">
      <center>
        <table width="650">
          <tr align="center">
            <td></td>
            <td> Yes </td>
            <td> No </td>
          </tr>
          <tr>
            <td><div align="left">1. Did you ever lose time from work or school due to gambling? </div></td>
            <td align="center"><input type="radio" name="q1" value="1" />            </td>
            <td align="center"><input type="radio" name="q1" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">2. Has gambling ever made your home life unhappy? </div></td>
            <td align="center"><input type="radio" name="q2" value="1" />            </td>
            <td align="center"><input type="radio" name="q2" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">3. Did gambling ever affect your reputation? </div></td>
            <td align="center"><input type="radio" name="q3" value="1" />            </td>
            <td align="center"><input type="radio" name="q3" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">4. Have you ever had remorse after gambling? </div></td>
            <td align="center"><input type="radio" name="q4" value="1" />            </td>
            <td align="center"><input type="radio" name="q4" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">5. Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties? </div></td>
            <td align="center"><input type="radio" name="q5" value="1" />            </td>
            <td align="center"><input type="radio" name="q5" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">6. Did gambling cause a decrease in your ambition or efficiency? </div></td>
            <td align="center"><input type="radio" name="q6" value="1" />            </td>
            <td align="center"><input type="radio" name="q6" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">7. After losing, did you feel you must return as soon as possible and win back your loses? </div></td>
            <td align="center"><input type="radio" name="q7" value="1" />            </td>
            <td align="center"><input type="radio" name="q7" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">8. After a win, did you have a strong urge to return and win more? </div></td>
            <td align="center"><input type="radio" name="q8" value="1" />            </td>
            <td align="center"><input type="radio" name="q8" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">9. Did you often gamble until your last dollar was gone? </div></td>
            <td align="center"><input type="radio" name="q9" value="1" />            </td>
            <td align="center"><input type="radio" name="q9" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">10. Did you ever borrow to finance your gambling? </div></td>
            <td align="center"><input type="radio" name="q10" value="1" />            </td>
            <td align="center"><input type="radio" name="q10" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">11. Have you ever sold anything to finance your gambling? </div></td>
            <td align="center"><input type="radio" name="q11" value="1" />            </td>
            <td align="center"><input type="radio" name="q11" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">12. Were you reluctant to use &quot;gambling money&quot; for normal expenditures? </div></td>
            <td align="center"><input type="radio" name="q12" value="1" />            </td>
            <td align="center"><input type="radio" name="q12" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">13. Did gambling make you careless of the welfare of yourself or your family? </div></td>
            <td align="center"><input type="radio" name="q13" value="1" />            </td>
            <td align="center"><input type="radio" name="q13" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">14. Did you ever gamble longer than you planned? </div></td>
            <td align="center"><input type="radio" name="q14" value="1" />            </td>
            <td align="center"><input type="radio" name="q14" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">15. Have you ever gambled to escape worry or trouble? </div></td>
            <td align="center"><input type="radio" name="q15" value="1" />            </td>
            <td align="center"><input type="radio" name="q15" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">16. Have you ever committed, or considered committing, an illegal act to finance gambling? </div></td>
            <td align="center"><input type="radio" name="q16" value="1" />            </td>
            <td align="center"><input type="radio" name="q16" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">17. Did gambling cause you to have difficulty in sleeping? </div></td>
            <td align="center"><input type="radio" name="q17" value="1" />            </td>
            <td align="center"><input type="radio" name="q17" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">18. Do arguements, disappointments, or frustrations create within you an urge to gamble? </div></td>
            <td align="center"><input type="radio" name="q18" value="1" />            </td>
            <td align="center"><input type="radio" name="q18" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">19. Did you ever have an urge to celebrate any good fortune by a few hours of gambling? </div></td>
            <td align="center"><input type="radio" name="q19" value="1" />            </td>
            <td align="center"><input type="radio" name="q19" value="0" />            </td>
          </tr>
          <tr>
            <td><div align="left">20. Have you ever considered self-destruction or suicide as a result of your gambling? </div></td>
            <td align="center"><input type="radio" name="q20" value="1" />            </td>
            <td align="center"><input type="radio" name="q20" value="0" />            </td>
          </tr>
        </table>
        <div align="center">
          <input name="submit" type="submit" value="done" />
          &nbsp;&nbsp;&nbsp; 
          <input name="reset" type="reset" value="clear" />
        </div>
      </center>
    </form>
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