Professional referrals

Client info

• Client's first name: *
• Client's last name: *
• Client's Town or City: *
• Client's phone number: *
• Client's email address: *
• Client's date of birth: *
• Is the client affected by their own or another person’s gambling? *

  Gambler *

  Affected other *
• Type of Gambling *
• Client's ethnicity: *
• Has the client given us their permission to contact them by phone or email? *

  Yes *

  No *

Referrer info

• Name of referring agency: *
• Name of person directly involved with the client *
• Phone number: *
• Email: *
• Reason for referral *

Questions

• Is the client involved with any of the following:

  Probation

  Mental Health

  Legal

  Budgeting

  Other

  N/A
• Please describe:
• Is the client at risk in any of the following areas: *

  Suicide

  Self-Harm

  Family Violence

  Other

  N/A
• Please describe: