Referrals & Screening Questions
Professionals
Professional Referral Form
Gambling is a hidden addiction, and without specialised training the affects can be particularly difficult to spot. However, a client’s journey of recovery can begin from a very simple starter question,
Has your gambling or the gambling of someone close to you had a negative impact on your life?
By asking your service users this question, or the questions on our online screening tool, you are opening a discussion around problematic gambling and the negative impacts it can cause which is vitally important.
If you need to refer a service user into treatment, please complete our professional referral form below and one of our team will be in contact with them as soon as we can. All information you provide will be kept PRIVATE and CONFIDENTIAL.
Referrer Details
Referrer name *
Referrer name is required
Referrer contact number *
Referrer phone number is required
Referrer email
Referrer organisation *
Referrer organisation is required
Reason for referral *
Please specify the reason for referral
Please specify which methods of contact the referrer consents to (you must select at least one) *
Phone call
Text message
Voicemail message
Email
Please specify at least one method of contact
Client Details
Client name *
Client name is required
Client date of birth *
Client date of birth is required
Client contact number *
Client phone number is required
Client email
Client address
Client type
Gambler
Family member or Friend
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
Client’s preferred treatment location?
Client’s preferred treatment type?
Required
Do you confirm you have the client’s consent to make this referral to Breakeven? *
We are unable to accept professional referrals without the client’s consent.
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
*Referrer name is required
*Referrer phone number is required
*Referrer organisation is required
