GamCare Surrey

Are you making a third-party referral on behalf of a client?*

Yes
No

Organisation and name of person referring

You can complete the rest of this form with the clients details, however please let us know your contact information in case we need to contact you regarding this referral.

Referrer Email

Is the client aware of the referral?

Yes
No

Do you feel the client is high-risk?

Yes
No

Please provide any further details of risks, harms experience and/or other professionals involved

Your full name*

Your date of birth*

Your email*

If you don't have an email address, please call our team on 0148 338 5210 to register.

Your contact telephone number*

Please enter a phone number you are happy for us to call you on and leave voicemail if necessary.

Your full address*

Street Address Address Line 2 City ZIP / Postal Code

Please note this form is for clients in SURREY ONLY. If you live elsewhere in the UK please use our interactive map to find your nearest service.

Are you happy for us to contact you by:*

Email
Over the phone
Leaving a voicemail message
Post
Text message

We will communicate with you to confirm or cancel appointments.

Are you the gambler?*

If yes, please describe the gambling activity that you most commonly participate in:

How long do you feel that gambling has been a concern for you or for someone close to you?*

Is this the first time you have sought help because of gambling?*

Are you currently employed?*

Do you have any medical or psychiatric issues that we should be aware of?*

For instance, if there are any other professionals that you are in regular contact with such as your GP or a medical professional as we may need to contact them (with your consent).

Please indicate when you would usually be available for us to call and book your assessment:*

Monday to Friday AM
Monday to Friday PM

How did you find out about our service?

Comments

This field is for validation purposes and should be left unchanged.

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