Gambling Harms Professional Referral Form

Referrer Details

Patient Details

GP Details

Please note, we can only accept referrals for patients registered with a GP in Stoke-on-Trent, Staffordshire, Telford and Wrekin, Shropshire, Birmingham, Solihull, Black Country, Coventry, Warwickshire, Herefordshire and Worcestershire.

Further Details

Referral Reason


Thank you for taking time to complete this form. We aim to review your patients’ information within 72 hours, your patients’ health wellbeing and safety is of top priority to us.
Completing this form will lead to the referral being considered by Gambling Harms Clinic, delivered by Inclusion which is part of Midlands Partnership NHS Foundation Trust across Staffordshire and Telford. Please note that by completing this form a medical record will be created for your patient on our clinical system (iaptus).
To find out how Midlands Partnership NHS Foundation Trust manages information please click on this link to our Privacy Notice: (please copy and paste this link into new browser)
Please be advised that we may contact you by telephone which is usually from a private number. If you do not accept these calls, please let us know at your earliest convenience the best way for us to contact you.