Referrals & Screening Questions
Professionals
Professional Referral Form
Gambling is a hidden addiction, and without specialised training the affects can be particularly difficult to spot. However, a client’s journey of recovery can begin from a very simple starter question,
Has your gambling or the gambling of someone close to you had a negative impact on your life?
By asking your service users this question, or the questions on our online screening tool, you are opening a discussion around problematic gambling and the negative impacts it can cause which is vitally important.
If you need to refer a service user into treatment, please complete our professional referral form below and one of our team will be in contact with them as soon as we can. All information you provide will be kept PRIVATE and CONFIDENTIAL.
Referrer Details
Referrer name *
Referrer contact number *
Referrer email
Referrer organisation *
Reason for referral *
Please specify which methods of contact the referrer consents to (you must select at least one) *
Phone call
Text message
Voicemail message
Email
Client Details
Client name *
Client date of birth *
Client contact number *
Client email
Client address *
Client type
Gambler
Family member or Friend
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
Client’s preferred treatment location?
Client’s preferred treatment type?
Do you confirm you have the client’s consent to make this referral to Breakeven? *
I confirm that I am not a robot
I am not a robot
