Gambling Harms Self-Referral Form

Personal 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


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: (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.