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Self Referral Form
In order for us to know the best way to help you, please fill in the confidential questions below.
All information you provide will be kept PRIVATE and CONFIDENTIAL.
Your Details
Name *
Client name is required
Date of birth *
Date of birth is required
Gender *
Gender is required
Contact number *
Contact number is required
Email address
Address *
Address line 1 is required
Postcode is required
Preferred treatment type *
Preferred treatment type is required
Client type *
Gambler
Family member or Friend
Client type is required
How did you hear about Breakeven?
How are you feeling?
Please read each statement and think how often you felt that way last week. Then tick the box which is closet to this.
I have felt tense, anxious or nervous *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I have felt I have someone to turn to for support when needed *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I have felt able to cope when things go wrong *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
Talking to people has felt too much for me *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I have felt panic or terror *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I made plans to end my life *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I have had difficulty getting to sleep or staying asleep *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I have felt despairing or hopeless *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
I have felt unhappy *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
Unwanted images or memories have been distressing me *
Not at all
Only occasionally
Sometimes
Often
Most or all of the time
Selecting an option is required
Confidentiality agreement
I confirm I have read and agree to the Information and Confidentiality Agreement
I confirm
Confirmation you have read the Information and confidentiality Agreement is required
I agree for Breakeven to contact me
I agree
Agreeing to Breakeven contacting you is required
When we contact you to arrange a telephone assessment, please specify any methods of contact you DO NOT consent to
Phone call
Text message
Voicemail message
Email
I confirm that if I do not live within Breakeven Treatment area or Breakeven feel I would benefit from another treatment provider in the area, I give consent for Breakeven to pass on my details
I confirm
I confirm that I am not a robot
I am not a robot
Please confirm you are not a robot
Please check the form is complete
*Client name is required
*Date of birth is required
*Gender is required
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WE CAN HELP
Take a positive step forward and contact us now.