Online Treatment Registration Form

Register for Online Treatment

If you would like to access GamCare treatment online, please complete the form below.

First name*
Last name*
Please confirm if you were emailed a link to this form by our treatment team (a facilitated referral)*
Date of Birth*
Date Format: DD slash MM slash YYYY
Email address*
Contact telephone number*
Your Full Address*
Street Address Address Line 2 City ZIP / Postal Code
We will communicate with you to confirm or cancel appointments and for follow ups after treatment. We will generally communicate by email, but there may be time when we need to call or text you. Please indicate the ways you are happy for us to contact you here:*
- Over the phone
- Leaving a voicemail
- Sending a text message
- Please only contact me via email
Are you:*
What is your housing status?*
Your gender*
What best describes your ethnic background?*
What is your relationship status?*
How many children do you have?*
Please enter a number from 0 to 20.
Are you responsible for the care of children under 18?*
Do you have carer responsibilities for a vulnerable adult?*
If you answered yes to either of the above questions, please provide their names and dates of birth below:
Do these children or vulnerable adults live with you?
If no, with whom are they living and where?
Please provide the name of the householder and the address where these children or vulnerable adults live.
Has your gambling had an impact on a child or vulnerable adult's welfare?*
If you are not the gambler, please answer to the best of your ability.
Have you ever had any involvement with statutory services? **
What is your employment status*
How did you hear about our service?

In the last 12 months, have you bet more than you could really afford to lose?
If you are not the gambler, please skip to the next page.
In the last 12 months, have you needed to gamble with larger amounts of money to get the same feeling of excitement?
If you are not the gambler please skip to the next page.
In the last 12 months, when you gambled, did you go back another day to try and win back the money you lost?
If you are not the gambler please skip to the next page.
In the last 12 months, have you borrowed money or sold anything to get money to gamble?
If you are not the gambler please skip to the next page.
In the last 12 months, have you felt that you might have a problem with gambling?
If you are not the gambler please skip to the next page.
In the last 12 months, has gambling caused you any health problems, including stress or anxiety?
If you are not the gambler, please skip to the next page.
In the last 12 months, have people criticised your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?
If you are not the gambler please skip to the next page.
In the last 12 months, has your gambling caused any financial problems for you or your household?
If you are not the gambler please skip to the next page.
In the last 12 months, have you felt guilty about the way you gamble or what happens when you gamble?
If you are not the gambler please skip to the next page.

Do you experience any of the following negative impacts of gambling?*
Please select all that apply.
Domestic abuse can take many forms - emotional, physical, verbal, sexual, psychological, neglect and financial abuse. Considering this, do you have any concerns about abuse in your own situation?*
Do you have any addictions (not considering your gambling)?*
Please select all that apply.
Do you have any disabilities or mental health problems?*
Please select all that apply.
Are you receiving treatment for any other diagnosed mental health problem?*
Have you already registered for counselling/treatment elsewhere?*
If you have already registered for counselling elsewhere, where was this?
Have you ever been suicidal?*
If you currently feel distressed or suicidal, before registering for our services please contact your GP, the Samaritans on 116 123 or the emergency services on 999.
If yes, when did you last feel suicidal?
If you currently feel distressed or suicidal, before registering for our services please contact your GP, the Samaritans on 116 123 or the emergency services on 999.
Please provide your GP name / surgery:*
All clients need to provide their GP name, surgery address and phone number. We would generally only contact your GP with your permission and under certain circumstances (see our Terms and Conditions).
Please provide your GP surgery address:*
Street Address Address Line 2 City ZIP / Postal Code

We would generally only contact your GP with your permission and under certain circumstances (see our Terms and Conditions).
Please provide your GP contact telephone number:*
We would generally only contact your GP with your permission and under certain circumstances (see our Terms and Conditions).
Please check this box to confirm that you have read and agree to our Terms and Conditions:*
- I agree
Please tick to confirm that you provide consent for us to follow up with you after treatment:*
As part of GamCare's online treatment we provide access to our Gambling Recovery Course, which is delivered in a group format. If there are any reasons that you feel that this would not be suitable for you, please tell us here, so that alternative treatment options can be considered.
If you are affected by a friend or family member’s gambling, we can offer one-to-one support.
Before you begin treatment, a short assessment is required to discuss your needs. Please state when you are likely to be available for an online assessment.*
Please note that most assessment appointments are Monday - Friday, between 9am - 5pm. If an evening appointment is required, there is likely to be a longer wait. The more flexible you can be, the quicker we can offer you an appointment. Please let us know the days and times you are generally available.
Please enter your full name as your signature:*
Comments
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Online Treatment Registration Form

Register for Online Treatment

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