Gambling Harms Self-Referral Form
Personal Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Date of Birth (This service is for people ages 18 and above only):*
Gender:*
Male
Female
Not known
Not specified
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Home Phone Number:
Permission to leave voicemail?:
Yes
No
Mobile Phone Number:
Permission to leave voicemail?:
Yes
No
Permission to send SMS Text reminders?:
Yes
No
Email Address:*
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.
GP Surgery:*
GP Name:
Further Details
Nationality:*
Please Select A Value...
English
Scottish
Welsh
Irish
British
Other
Ethnicity:*
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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
Are you able to communicate in English?:*
Yes
No
Unknown
Do you need an interpreter?:*
Yes
No
Preferred Language:
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese and Vietnamese
Dutch
English
Farsi (Persian)
Finnish
Flemish
French
Gaelic
German
Greek
Gujarati
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Norwegian
Pashto (Pushtoo)
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Relationship Status:*
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Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Sexuality:*
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Heterosexual
Lesbian or gay
Bisexual
Other
Not stated
Not known
Unknown
Do you have a long term medical condition? (e.g. cancer, diabetes, heart disease, stroke):*
Please Select A Value...
Yes
No
Don't Know/Not Sure
Do not wish to say
If yes, please specify:
Are you ex-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
Main Reason for Referral:*
Please list any dates and times unsuitable for an appointment:
How did you hear about the West Midlands Gambling Harms Clinic?:*
Please Select A Value...
Social Media
TV/Radio
Professional (ie Nurse, GP, Social Worker etc)
Friends and Family
Website
Other (please state below)
If Other, please state:
Declaration
Thank you for taking time to complete this form. We aim to review your information within 72 hours, your health wellbeing and safety is of top priority to us.
Completing this form will lead to your 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 you on our clinical system (iaptus).
To find out how Midlands Partnership NHS Foundation Trust manages your information please click on this link to our Privacy Notice: https://www.mpft.nhs.uk/about-us/information-governance (please copy and paste this link into a 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.
By ticking the consent declaration and submit I agree to Inclusion contacting me using the details given above:*
I consent to the above declaration
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