Problem Gambling Materials Order Form

If you would like to request problem gambling materials, please fill out the form below.

(* Denotes Required Fields)

Contact Information
First Name: *
Last Name: *
Organization/Agency: *
Email Address: *
Confirm Email Address: *
Phone Number:
Material Requests
Please specify quantities of requested materials below
Brain Biology - English :
Brain Biology - Spanish :
What About You - English:
Choices and Guidelines Booklet:
Responsible Play the CT Way Bag :
PRIDE Chip Clips:
Risk Ranking Cards:
College Phone Wallet:
Computer Webcam Cover:
College Stylus Pens:
College Infinity Fold :
Know the Risks Pamphlet :
Poster Requests
Please note there is a limit of 10 for each poster requested
Know the Risks Warning Signs - English :
Know the Risks Responsible Gambling :
Know the Risks Why it Matters - English :
Know the Risks Why it Matters - Spanish :
Know the Risks Before You Gamble:
Be A Winner:
Don't Gamble:
Gambling Lifeline:
Requested materials and posters will be used for
Please check all that apply: *	Health Fair Event Training/Workshop Conference Client/Patient/Student Education Other
Pick Up/Mail
Note: Shipment takes approximately 2 weeks
Please select one: *	I will pick up requested materials at the CT Clearinghouse (334 Farmington Ave. Plainville CT) Please ship requested materials to me
If shipment is chosen, please submit a shipping address
First Name :
Last Name :
Organization/Agency :
Address:
Address 2 :
City :
State:
Zip Code:
Email Address:
Phone Number:
Additional Notes :
Any questions or requests can be sent to Mae Gereg at magereg@wheelerclinic.org