Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
  Date of Birth:  * Birth Sex: 
  Address: City:  
  State: Zip Code :  
  Phone No:  
For the purpose of these questions, “gambling” means buying lottery tickets, gambling at a casino, playing cards or dice for money, betting on sports games, playing slot machines, video poker or other video gambling, gambling on the internet, betting on horses or dogs, playing bingo or keno.
* During the past 12 months how many times have you gambled?    
If the answer is 5 or more, then proceed to the following questions:
1. Have you ever felt restless, on edge or irritable when trying to stop or cut down on gambling?
1 - Yes   0 - No  
2. Have you had to ask other people for money to help deal with financial problems that had been caused by gambling?
1 - Yes   0 - No  
3. Have you tried to hide how much you have gambled from your family or friends?
1 - Yes   0 - No  
4. Have you tried to cut down or stop your gambling?
1 - Yes   0 - No  
5. Have you increased your bet or how much you would spend, in order to feel the same kind of excitement as before?
1 - Yes   0 - No  
6. Did you think about gambling even when you were not doing it? (Remembering past gambling experiences, or planning future gambling?)
1 - Yes   0 - No  
7. Did you go to gamble when you were feeling down, stressed, angry or bored?
1 - Yes   0 - No  
8. Did you ever try to win back the money that you had recently lost?
1 - Yes   0 - No  
9. Has your gambling caused problems in your relationships or with work?
1 - Yes   0 - No  
* I have answered all questions to the best of my ability
End of SBIRT
SBIRT Score:
1-3 = Screening and Feedback; 4-6 = Gambling Brief Intervention; 7 or more = Gambling Brief Intervention and Referral to Gambling Treatment
If this screen is 5 or higher, please assign form to the Gambling Contract Manager.
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.