Referral Form

Personal Details

Title:*

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:*

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:

Nationality:*

Ethnicity:*

Are you able to communicate in English?:*

Yes

No

Unknown

Do you need an interpreter?:*

Yes

No

Preferred Language:

Relationship Status:*

Sexuality:*

Do you have a long term medical condition? (e.g. cancer, diabetes, heart disease, stroke):*

If yes, please specify:

Are you ex-British Armed Forces?:*

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?:*

If Other, please state:

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

Please complete the captcha

Gambling Harms Self-Referral Form

Personal Details

GP Details

Further Details

Declaration