You can use this self-referral form to refer yourself to the Southern gambling Service (SGS).
Note: where a box indicates '** None' please select the correct option from the dropdown list by clicking on the box.
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- The field Full name is required.
- The field Home address is required.
- The field Do you consent to being contacted by the SGS via your email address, telephone or SMS with clinic information? is required.
- The field Email address is required.
- The field Date of birth is required.
- The field NHS number is required.
- The field Gender is required.
- The field Is your gender identity the same as your sex recorded at birth? is required.
- The field Sexual Orientation is required.
- The field Pregnancy and maternity is required.
- The field Relationship status is required.
- The field Ethnicity is required.
- The field Dependants (e.g children) is required.
- The field First language is required.
- The field Have you previously been under the care of SGS for previous treatment? is required.
- The field Next of Kin details (please include name, relationship and mobile number) is required.
- The field GP name, address and phone number is required.
- The field Do you have access to the internet for virtual (TEAMS) meetings? is required.
- The field Do you have access to private space for a videocall with the SGS clinical team? is required.
- The field Are you a university student? is required.
- The field Are you serving or ex-military personnel is required.
- The field Homelessness is required.
- The field In your own words, why are you referring yourself to the Southern Gambling Service is required.
- The field 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. is required.
- The field Do you consent for the SGS to share and receive necessary information with local authorities, NHS Professional Medical and NHS Healthcare services? is required.
- The field Do you have any other mental health problems or diagnosis? is required.
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- You need to agree to the privacy policy.