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 method(s) of contact that they DO consent to *
Referrer contact number *
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 method(s) of contact that they DO consent to *
Client contact number *
Client address *
Client type
Gambler
Family member or Friend
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?
Do you confirm for the details to be saved on Breakeven’s client system?
I confirm that I am not a robot *
I am not a robot
