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Self Referral

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 *

Method(s) of contact that you DO consent to *

Please select... *

Contact number *

Address *

Preferred treatment type *

Please select *

Client type *

Gambler

Family member or Friend

How did you hear about Breakeven?

How are you feeling?

Please read each statement and think how often you felt that way last week. Then tick the box which is closest 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 that I am filling out this form for myself? *

I confirm

I confirm I have read and agree to the Information and Confidentiality Agreement *

I confirm

I agree for Breakeven to contact me using the method(s) I have consented to *

I agree

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

SUBMIT

CONTACT US

We are here to help

Assessment Tool

Use our self assessment tool

START

Self Refer

FILL IN A SELF REFERRAL FORM

Self Refer

SPEAK TO A FRIENDLY VOICE

WE CAN HELP

Take a positive step forward and contact us now.

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 *

Method(s) of contact that you DO consent to *

Please select... *

Contact number *

Address *

Preferred treatment type *

Please select *

Client type *

Gambler

Family member or Friend

How did you hear about Breakeven?

How are you feeling?

Please read each statement and think how often you felt that way last week. Then tick the box which is closest 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 that I am filling out this form for myself? *

I confirm

I confirm I have read and agree to the Information and Confidentiality Agreement *

I confirm

I agree for Breakeven to contact me using the method(s) I have consented to *

I agree

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

SUBMIT