September 2023 PG Screening Registration

2023 Recovery Month PG Screening Event Registration

Thank you for making the time to screen the people you work with for problem gambling!

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* 1. By checking this box I agree to complete a short follow up survey indicating the number of people I/my agency screened.

I agree

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* 2. Name of agency:

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* 3. Name of contact person:

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* 4. Email address of contact person:

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* 5. County your agency/practice serves:

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* 6. Dates of your screening event:

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* 7. Are you an OASAS provider?

Yes

No

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* 8. Have you/your agency held a PG screening in before?

Yes

No