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Southern Gambling Service patient referral form

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Southern Gambling Service
Southern Gambling Service patient referral form

You can use this self-referral form to refer yourself to the Southern gambling Service (SGS).

Personal details

Full name Required

Previous surname (if applicable)

Home address

Address 1

Address 2

City

Country

County

Postal Code

Do you consent to being contacted by the SGS via your email address, telephone or SMS with clinic information? Required

Yes

No

Email address Required

Date of birth Required

NHS number Required

Gender Required

Is your gender identity the same as your sex recorded at birth? Required

Sexual Orientation Required

Pregnancy and maternity Required

Not applicable

Currently pregnant

Currently breastfeeding

Given birth in the last 26 weeks

Prefer not to say

Relationship status Required

Religion

Ethnicity Required

Dependants (e.g children) Required

First language

Have you previously been under the care of SGS for previous treatment? Required

Next of Kin details (please include name, relationship and mobile number) Required

Mobile telephone number

Landline number

GP name, address and phone number Required

Do you have access to the internet for virtual (TEAMS) meetings? Required

Yes

No

Do you have access to private space for a videocall with the SGS clinical team? Required

Yes

No

Current location (if different from home address)

Are you a university student? Required

Are you serving or ex-military personnel Required

Homelessness Required

I have never been homeless

I have a history of being homeless

I am currently homeless

Reason for self-referral

In your own words, why are you referring yourself to the Southern Gambling Service Required

History of gambling problems

How old were you when you started having problems with your gambling? Tell us briefly about how your gambling developed and what you are currently struggling with. Required

Do you consent for the SGS to share and receive necessary information with local authorities, NHS Professional Medical and NHS Healthcare services? Required

Do you have any other mental health problems or diagnosis? Required

Other medical history

Do you have any other medical problems?

Do you take any prescribed or non prescribed medication? If so please let us know

Do you receive help from any other professional healthcare / social care / agencies at the moment? If yes please list them including any named case workers or care co-ordinators.

Consent

Please be aware that the SGS may need to liaise with your GP, Local authorities and/or other relevant health services involved in your care to provide you with a comprehensive assessment and plan and to confirm your medical history where appropriate.

Privacy Policy

I agree to the privacy policy

Southern Health is proud to be a University Hospital Trust.

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Southern Health NHS Foundation Trust
Sterne 7, Tatchbury Mount, Calmore, SO40 2RZ
Telephone: 02382 310000

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