CT Clearinghouse

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: *
Phone Number: *
Pamphlet Requests
Please specify quantities of requested materials below  
Brain Biology and Gambling Disorder (English):
Brain Biology and Gambling Disorder (Spanish) :
Choices and Guidelines Booklet (English):
Choices and Guidelines Booklet (Spanish):
Before You Gamble, Know the Risks (5" x 5"):
Before You Gamble, Know the Risks (8" x 8"):
What About You - Spanish:
Online Sports Betting: Don't Gamble with Your Future (English):
Online Sports Betting: Don't Gamble with Your Future (Spanish):
College Students Gamble Responsibly:
Teens and Online Gambling: A Losing Bet (English):
Teens and Online Gambling: A Losing Bet (Spanish):
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:
Wallet Card Requests
Tools: "Can You Rank the Risks?" Activity Set Requests (limit 5 Sets)
"Can You Rank the Risks?" activity sets are limited to five (5) sets per organization, coalition, school, or business. Please list the number of activity sets needed and plans for their use in the spaces provided below. 
Number of sets (limit is 5 per organization):
Please describe plans for use::
Tools: Know the Risks Phone Lock Boxes Requests (limit 20 per organization)
The phone lock boxes are limited to 20 per organization, coalition, school, or business. Please list the number of phone lock boxes needed and plans for their use in the spaces provided below. 
Number of phone lock boxes (limit 20 per organization):
Please describe plans for use:
Promotional Item Requests
Know the Risks Stress Relief Turtle (limit 20 per organization):
College Computer Webcam Cover (limit 20 per organization):
Responsible Play Red Bags (limit 20 per organization):
Responsible Play PRIDE Chip Clips (limit 20 per organization):
Requested materials and posters will be used for
Please check all that apply: *
Pick Up/Mail
Note: Shipment takes approximately 2 weeks  
Please select one: *
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 Cathy Sisco at csisco@wheelerhealth.org.