1 client is ___ a problem gambler b person affected by 2 if indicate relationship to spouse significant other c parent d child e specify _________________________ 3 residence ______________ city county state 4 gender male female 5 marital status married living with divorced separated single f widowed 6 age under 18 24 25 34 35 44 45 54 55 64 g 65 7 ethnicity optional african american asian caucasian hispanic native _______________________ 8 how got treatment mark all that apply referral from helpline 800 next step _________________ az council on comp gambling friend former or family member healthcare provider gamblers anonymous ga newspaper h television ad
