Thank you for your interest in the Westside Gambling Treatment Veterans Program. The information you provide in this form will be used only for the purpose of contacting you, conducting a confidential screening, and determining your eligibility for our no cost enhanced outpatient (EOP) services for gambling disorder, online gaming issues, stock or crypto trading problems, and sports betting. Your information will be reviewed solely by licensed clinical social workers and registered associate clinical social workers in California. All clinicians are governed by the California Board of Behavioral Sciences and are required to follow professional standards regarding confidentiality, data handling, and the protection of client information. We do not sell, trade, or share your information with any outside parties, and it is not used for advertising or any purpose unrelated to screening and enrollment. Please note that completing this form does not establish a therapist-client relationship, does not constitute acceptance into the program, and does not obligate you to participate in services. A clinician will contact you directly to complete a confidential screening. If you meet criteria for services, we will discuss next steps, scheduling, and any documentation needed for enrollment. Information submitted through this form is kept as confidential as possible within the limits of online communication platforms. Once you engage in a clinical screening by phone or video, your information will be protected in accordance with California law and the ethical standards of the Board of Behavioral Sciences. We encourage you not to include highly sensitive details in this form; those can be discussed privately during your screening. By submitting this form, you acknowledge and consent to our use of your information solely for screening and potential enrollment in the program.