First Name
Last Name
Email
Phone Number
Reason for contacting us?—Please choose an option—Negative Substance Abuse experienceNegative Gambling ProblemCalling on behalf of family members/friends Addiction/Gambling and requires informationReports Anxiety/Depression from family members/friends Substance Abuse/GamblingExperiencing Mental Health ProblemExperiencing Pyschiatric ProblemExperiencing Emotional ProblemExperiencing Relationship ProblemOther
Notes
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