Contact Us
Self Referral Form
In order for us to know the best way to help you, please fill in the confidential questions below.
All information you provide will be kept PRIVATE and CONFIDENTIAL.
Your Details
Name *
Date of birth *
Gender *
Contact number *
Email address
Address *
Preferred treatment type *
Client type *
Gambler
Family member or Friend
How are you feeling?
Please read each statement and think how often you felt that way last week. Then tick the box which is closet to this.
I have felt tense, anxious or nervous *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have felt I have someone to turn to for support when needed *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have felt able to cope when things go wrong *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Talking to people has felt too much for me *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have felt panic or terror *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I made plans to end my life *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have had difficulty getting to sleep or staying asleep *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have felt despairing or hopeless *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
I have felt unhappy *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Unwanted images or memories have been distressing me *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Confidentiality agreement
I confirm I have read and agree to the Information and Confidentiality Agreement
I confirm
I agree for Breakeven to contact me
I agree
When we contact you to arrange a telephone assessment, please specify any methods of contact you DO NOT consent to
Phone call
Text message
Voicemail message
Email
I confirm that if I do not live within Breakeven Treatment area or Breakeven feel I would benefit from another treatment provider in the area, I give consent for Breakeven to pass on my details
I confirm
I confirm that I am not a robot
I am not a robot
CONTACT US
We are here to help
WE CAN HELP
Take a positive step forward and contact us now.
