Chat Registration:

The following is used for conversational purposes only and is optional.
First Name
Last Name
After this brief chat registration you will be able to chat directly with a problem gambling counselor. 
Reason for visit * 
Are you thinking of hurting yourself or someone else? * 

To enable Google Chat or SMS (text) communications please provide the following info:
Cellular Number:

(more details)  

Verification: To complete the registration, solve the CAPTCHA and click "Start".
(this additional step helps prevent malicious and automated attempts to access the site)