Gambling Self-Exclusion Program Address Verification Form

Gambling Self-Exclusion Program Address Verification

Taking control of your gambling habits is a courageous step, and a self-exclusion program is an effective tool for protecting yourself from further harm. This gambling self-exclusion address verification form streamlines the enrollment process by collecting all required documentation in one secure, confidential submission.

Who this form is for

This template is designed for addiction services organizations, state gaming commissions, casino operators, responsible gambling programs, and mental health clinics that help individuals voluntarily exclude themselves from gambling venues and online platforms. It's also useful for social workers, counselors, and community support programs managing self-exclusion registrations.

What makes this form essential

Self-exclusion programs require robust identity and address verification to ensure excluded individuals are properly flagged across gambling venues and platforms. This form collects government-issued ID, utility bills, casino membership cards, and support program enrollment details in a single workflow—replacing scattered emails, phone calls, and in-person appointments.

Built with Paperform, this template offers conditional logic to adapt questions based on the applicant's situation, secure file uploads for sensitive documents, and a professional, compassionate design that respects the gravity of the decision. You can customize the form to match your organization's branding and compliance requirements, then embed it on your website or share it as a standalone link.

Automate what comes next with Stepper

Once someone submits their self-exclusion application, Stepper can automate the verification and enrollment workflow. Route submissions to compliance officers for review, send confirmation emails with next steps, update your CRM or case management system, and trigger notifications to partner casinos or gaming platforms—all without manual data entry. Learn more about Stepper.

Secure, compliant, and compassionate

Paperform is SOC 2 Type II compliant and GDPR-ready, ensuring sensitive personal information is handled with care. Customize success messages to include support resources, hotline numbers, and reassurance that their information is confidential. This form helps you provide a dignified, efficient path for individuals seeking help.