I'm affected by someone else's gambling. Client Details Question Title * 1. Client Details Given Name (optional) Surname (optional) Address (optional) Suburb (optional) Question Title * 2. Date of Birth Date / Time Date Question Title * 3. What is your current postcode? 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 being Aboriginal or Torres Straight Islander? No Yes (Aboriginal) Yes (Torres Straight Islander) Yes, Both 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. Contact Phone Number Next