Referral type
Required
Are you an NHS registered healthcare professional / clinician?
Required
Are you a private or third sector registered healthcare professional / clinician?
Required
Patient details
Patient’s full name
Required
Previous surnames (if applicable)
Patient's address
Date of Birth
Required
Europe/London
NHS Number
Required
Gender
Required
Is your gender identity the same as your sex recorded at birth?
Required
Yes No Prefer not to say Not known
Sexual orientation
Required
Asexual Bisexual Gay man Heterosexual/ straight Lesbian/ Gay woman Pansexual Prefer to self-describe Prefer not to say Not known
Pregnancy and maternity
Required
Marital status
Required
Single Married Civil partnership Divorced / dissolved Civil Partnership Widowed / surviving partner in Civil Partnership Not disclosed Separated Cohabiting
Religion
Required
Ethnic background
Required
Arab Asian/ Asian British: Bangladeshi Asian/ Asian British: Chinese Asian/ Asian British: Indian Asian/ Asian British: Pakistani Asian/ Asian British: Any other Asian/ Asian British background Black/ Black British: African Black/ Black British: Caribbean Black/ Black British: Any other Black/ Black British baground Mixed/ Multiple ethnic groups: Asian and White Mixed/ Multiple ethnic groups: Black African and White Mixed/ Multiple ethnic groups: Black Caribbean and White Mixed/ Multiple ethnic groups: Any other Mixed/ Multiple ethnic groups background White: British/ English/ Northern Irish/ Scottish/ Welsh White: Irish White: Gypsy/ Traveller/ Irish Traveller White: Roma White: Any other White background Any other ethnic group Prefer not to say Not known
Dependant
Required
Children (at least one dependant child living with dependant) Adult (at least one dependant adult living with dependant) Dependants living in other household Other dependant(s)
First language
Required
English native speaker Non-English native speaker (language support not needed) Non-English speaker (language support needed) Other (special assistance required)
Known to SGS from previous treatment?
Required
Next of Kin detail (include name, relationship and mobile number)
Required
Mobile phone number
Required
Landline phone number
Required
Patients email
Required
GP name, address and phone number
Required
Does the patient have access to the internet for virtual (TEAMS) meetings?
Required
Patient’s current location (if different from home address)
Is the patient a university student?
Required
Is the patient a serving or ex-military personnel?
Required
Reason for referral
Rationale for referral. Please detail KEY bullet point information why help is sought including; age of onset, any gambling symptoms, and any other psychiatric history including alcohol or substances use, diagnosis)
Required
Other medical history
Does the patient have any other medical problems? Please list if they do.
Required
Does the patient take any prescribed / non-prescribed medication? Please list if they do.
Required
Does the patient have input from any other professional healthcare / social care / agencies? If yes please provide name, contact details, input type.
Required
Aims for referral to Southern Gambling Service
Aims from the referrer
Required
Aims from the person
Required
Risk assessment
If there are no significant risks, please enter “none known”.
Date of most recent risk assessment and name of person who completed it.
Required
Risk to self (including history of self-harm/suicidal ideation. Please include current and historical risks.
Risk of self-neglect (please include current and historical risks).
Required
Risk of financial vulnerability (please include current and historical risks).
Risk to others (if yes provide details, please include current and historical risks).
Driving related risks (please include current and historical risks).
Required
Safeguarding
Does the patient have a formal evidenced diagnosis of Learning Disability including Autism Spectrum Disorder or Autism?
Required
Are there safeguarding concerns around this person? If so, please detail below.
Required
Consent
Has the patient given consent to this referral?
Required
Has the patient given consent for SGS to share information with local authorities, GP and NHS healthcare professionals?
Required
Has the patient given consent to be contacted by the SGS via e-mail, telephone and SMS?
Required
Consent taken by
Required
Date and time consent gained
Required
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Europe/London
Is there any specific requested restriction on sharing information?
Required
If there is a specific restriction, please provide details.
Referrer details
Date of clinical assessment
Required
Europe/London
Name and job title of referrer
Required
Referring Team and NHS Trust/Organisation
Required
Signature of referrer
Required
Please provide your contact email address
Required
Contact telephone number
Required
Important contact sheets
Please complete where relevant to ensure that the appropriate links are made with the rest of the professionals in this case.
Primary Community contact or Care-Coordinator (please include name, job title, organisation, email and phone number).
Social work contact (please include name, job title, organisation, email and phone number).
Other third sector organisation (please include name, job title, organisation, email and phone number).
Other (please include name, job title, organisation, email and phone number).
Details of person completing this form (if not the referring clinician)
Name
Required
NHS Trust
Required
Job title
Required
Email address
Required
Telephone number
Required
Date
Required
Europe/London
