Gambling Addiction Self-Report Form — satirical meme
OFFICIAL FORM · EST. NEVER
♠ ♥ ♣ ♦
Gambling Addiction Self-Report Form
Complete all fields. Results may vary. House always wins.
0 / 7 fields completed
Type your name, then roll the dice to validate it
Roll the dice after typing your name
Enter your age and let the pit boss verify it
Enter your age, then press CHECK
Enter a valid email so the casino can definitely not contact you
Enter your email, then press CHECK
Each option is a coinflip — needs "heads" to confirm
Less than a year
1–3 years
3–10 years
Since birth, basically
Select an option and hope for heads
Spin the slots. Only 3 matching symbols count. Prize depends on icon rarity.
Spin until you hit 3 matching symbols
Select at least one — clicks are coinflips that may deselect other answers
Lost everything
Family pressure
I don't want to stop
Debt
Court-ordered
At least one reason must stick
⚠ Security Captcha
Select all RED roulette numbers.
Red and black squares use real roulette-number colors. Target may randomly switch.
Hold correct selection for 2 seconds.