Thank you for purchasing your session with the San Diego Center
for Pathological Gambling.

It is important that you now provide some contact and background information so that Dr. Pike
may be better able to assess your gambling problem, and to contact you for scheduling your
session time. Fill out this form in its entirety and click the SUBMIT button at the end of the form.
Please allow the therapist 24 hours to respond to this request for e-therapy. Returning patients
may skip these forms as your information has been previously received.
All Fields are Required
All gamblers
are escape
artists.



Replacing an
alcohol
problem with a
gambling
problem is like
changing seats
on the Titanic.
Comprehensive
Diagnostic
Assessment and
Treatment Program
First Name:
Last Name:
Sex / Gender:
Birthdate:
Marital Status:
Highest Education Achieved:
Email Address:
City in California:
Zip Code:
Have you had prior counseling?
If so, when and for what reason?
Are you currently on any psychiatric
medications? Please list.
Do you have a family history of mental
illness, substance abuse, or gambling?
Briefly describe any pertinent
medical history.
What is your preferred method of gambling?
Table Games
 Internet Gambling
 Sports Betting
Slots / Machines
 Horse / Dog Races
 Other:
Why are you seeking therapy now? Please be brief.
How did you find out about the San Diego Center for Pathological Gambling?
Internet Search
 Business Card / Flyer
 Court Testimony
Other:
Newspaper Article
 Lecture / Seminar
Television Interview
 Word of Mouth / Referral
Please click the "Yes" or "No" button to the following questions:
 
Yes
No
After losing money while gambling, do you go back another day to win back money      
you lost?
Have you ever claimed to be winning money from your gambling activities when in        
fact you lost?
Do you ever spend more time or money gambling than you intended?
Have people ever criticized your gambling?
Have you ever felt guilty about the way you gamble or about what happens when        
you gamble?
Have you ever felt that you would like to stop gambling but didn't think that you could?
Have you ever hidden betting slips, lottery tickets, gambling money, or other signs of    
gambling from your spouse or partner, children, or other important people in your life?
Have you ever argued with people you live with over how you handle money for          
gambling?
Have you ever missed time from work or school due to gambling?
Have you ever borrowed from someone and not paid them back as a result of your      
gambling?
Have you ever borrowed from household money to finance gambling?
Have you ever borrowed money from your spouse or partner to finance gambling?
Have you ever borrowed money from other relatives or in-laws to finance gambling?
Have you received loans from banks, loan companies or credit unions for gambling       
or to pay gambling debts?
Have you ever made cash withdrawls on credit cards such as Visa or MasterCard      
to get money to gamble with or to pay gambling debts? (Not including ATM cards.)
Have you ever received loans from loan sharks to gamble or to pay gambling debts?
Have you ever cashed in stocks, bonds, or other Securities to finance gambling?
Have you sold personal or family property to gamble or pay gambling debts?
Have you ever borrowed money from your checking account by writing checks that    
bounced to get money for gambling or to pay gambling debts?
Do you feel that you have ever had a problem betting money or gambling?
Terms and Conditions - Legal Disclaimer
I (you as the user) hereby consent to engage in online counseling with Dr. Suzanne G.
Pike, PhD. and the San Diego Center for Pathological Gambling as the main venue for my
psychotherapy treatment. I understand that e-therapy includes the practice of health care
delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer
of medical data, and education using interactive audio, video, and/or data
communications. I understand that e-therapy may also involve the communication of my
medical/mental health information, both orally and visually, to other health care
practitioners where required by law.

I understand that I have the following rights with respect to e-therapy:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to
future care or treatment nor risking the loss or withdrawal of any benefits to which I would
otherwise be entitled.

(2) The laws that protect confidentiality of my medical information also apply to e-therapy.
As such, I understand that the information disclosed by me during the course of my
therapy is generally confidential. However, there are both mandatory and permissive
exceptions to confidentiality including, but not limited to: reporting child, elder, and
dependent adult abuse; expressed threats of violence towards an ascertainable victim;
and where I make my mental or emotional state an issue in a legal proceeding.

I also understand that the dissemination of any personally identifiable images or
information from the e-therapy interaction to researchers or other entities shall not occur
without my written consent.

(3) I understand that there are risks and consequences from e-therapy. These may
include, but are not limited to, the possibility, despite reasonable efforts on the part of my
psychotherapist, that: the transmission of my medical information could be disrupted or
distorted by technical failures; the transmission of my medical information could be
interrupted by unauthorized persons.

In addition, I understand that e-therapy based services and care may not yield the same
results nor be as complete as face-to-face service. I also understand that if my
psychotherapist believes that I would be better served by another form of
psychotherapeutic service (ie. face-to-face service), I will be referred to a psychotherapist
in my area who can provide such service. Finally, I understand that there are potential risks
and benefits associated with any form of psychotherapy, and that despite my efforts and
the efforts of my psychotherapist, my condition may not improve and in some cases may
even get worse.

(4) I understand that I may benefit from e-therapy, but results cannot be guaranteed or
assured.

(5) I understand that I have the right to access my medical information and copies of
medical records in accordance with California law, that these services may not be covered
by insurance and that if there is intentional misrepresentation, therapy will be terminated.

I understand that the information I provide on the following online form may be published
at a later date although no real names will be used. I agree to forever release, discharge
and indemnify Dr. Suzanne G. Pike and the San Diego Center for Pathological Gambling
from all actions, suits, and claims arising from receiving counseling on this site.

I have read and understand the information provided above.
By clicking the Submit button below, you send this questionnaire and
you agree to the terms and conditions of the above disclaimer.