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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
What are you gambling on? *
How long have you been gambling for? *
How long has it been a problem? *
How many days in the last 30 have you gambled on? *
Do you have any debts due to your gambling?
Are you taking any prescribed medication?
Accommodation needs *
How gambling is impacting you
Have you bet more than you could really afford to lose? *
Never
Sometimes
Most of the time
Almost always
Have you needed to gamble with larger amounts of money to get the same feeling of excitement? *
Never
Sometimes
Most of the time
Almost always
When you gamble, do you go back another day to try to win back the money you lost? *
Never
Sometimes
Most of the time
Almost always
Have you borrowed money or sold anything to get money to gamble? *
Never
Sometimes
Most of the time
Almost always
Have you felt that you might have a problem with gambling? *
Never
Sometimes
Most of the time
Almost always
Has gambling caused you any health problems, including stress or anxiety? *
Never
Sometimes
Most of the time
Almost always
Have people criticised your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true? *
Never
Sometimes
Most of the time
Almost always
Has gambling caused any financial problems for you or your household? *
Never
Sometimes
Most of the time
Almost always
Have you felt guilty about the way you gamble or what happens when you gamble? *
Never
Sometimes
Most of the time
Almost always
How are you feeling?
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 have 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
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