East of England Gambling Service
If you are contacting us in an emergency, in a crisis or experiencing suicidal thoughts please do not wait. There is help available:
- Ring 111 and either speak to an operator or select option 2 for urgent mental health support.
- Go to www.nhs.uk/service-search/mental-health/find-an-urgent-mental-health-helpline to find a local mental health helpline in your area.
- Contact Samaritans on 116 123 or email jo@smaratians.org for a reply within 24 hours.
- Text SHOUT to 95258 to contact the Shout Crisis Text Line or text YM if you are under 19
- Contact Your GP.
- Call 999 or attend your local A&E if someone’s life is at risk or if you do not feel you can keep yourself or someone else safe.
Is this referral a self-referral / professional referral?:*
self- referral
professional referral
Fields marked with * are mandatory
If Professional referrer
Professional referral – please confirm that the person you are referring is aware of this referral and has consented to us contacting them. (the person you are referring will be referred to as ‘you’ from here on in
I confirm:
Yes
Referrer Name:
Referrer contact details:
If self referral
Are you referring yourself for support with your gambling, or are you referring yourself for support as someone affected by another person’s gambling?:*
Support for my gambling
Support for me as someone affected by another person’s gambling
Your Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Date of Birth:*
Address Line 1:*
Address Line 2:
Town/City:
Postcode:*
Permission To Contact By Post:*
Yes
No
Please provide a Home phone, Mobile phone, or both.
Home Number:
Permission to leave voicemail:
No
Yes
Mobile Number:
Permission to leave voicemail:
No
Yes
Permission to contact by SMS:*
No
Yes
Email:*
Can we contact you via email:*
Yes
No
Do you require an interpreter or any support with accessing the service?:*
Yes
No
If yes – which language are you most comfortable with or what type of support would help?:
NHS Number (if known):
Nationality:*
Please Select A Value...
English
Scottish
Welsh
Irish
British
Other
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Sexuality:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Unknown
Gender:*
Not known
Male
Female
Not specified
If you wish, please let us know how you currently describe your gender?:
Gender is the same as that assigned at birth
Transgender
Non Binary, Non conforming, gender fluid
In another way
Prefer not to say
GP details and number:*
Our main service hours are Monday – Friday 9am – 5pm. Are there any times that are more convenient to contact you?:
Are you a university student currently studying?:*
Yes
No
If yes is your correspondence address your university residence?:
Yes
No
Are you a veteran of the British Armed forces?:*
Please Select A Value...
Dependant of a ex-serving member
No
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Yes - ex services
Are you a carer?*
Yes
No
Not Stated
Reason For Referral
Tell us about the difficulties you have been experiencing with gambling and why you feel you need help:*
If you are a friend, family member or carer and are referring yourself for support, please describe what has been happening for you:
Have you ever received help or support from a gambling service before?:*
Yes
No
If yes please provide details:
Please tell us if you feel you are struggling with any of the following:
Mental health
Physical illness/ disability
Outstanding legal issues / under probation
Illicit drug use in the last 30 days
Alcohol problems
Any other addictive behaviours
Homelessness
Current self-harm
Current suicidal thoughts
Risk of causing harm to others
Worried about the impact of gambling on the family – including children
Social services involvement
Is there anything else we have missed that you are worried about?:
Please tell us about any teams/services you are currently receiving help from
If you have them, please give us the names and contact details of anyone in the teams.
Do we have consent to liaise with this team if it helps with your care?:*
Yes
No
Can you please list any medications you are currently prescribed.
CNWL share your clinical information with other healthcare professionals involved in your care, to support better informed clinical treatment and help reduce clinical risk. A patient information leaflet is available on request from services and further details can be found on the Trust website.
How did you hear about us?
Please Select A Value...
GP
Mental Health Professional
Social Care Worker
Other professional
Other gambling treatment provider
Social media
TV/Radio
Friend / family member
Website
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