Personal details
Full name
Required
Previous surname (if applicable)
Home address
Do you consent to being contacted by the service via your email address, telephone or SMS with clinic information?
Required
Email address
Required
Date of birth
Required
NHS number
Required
Gender
Required
** None Male Female Not specified
Is your gender identity the same as your sex recorded at birth?
Required
** None Yes No Prefer not to say Not known
Sexual Orientation
Required
** None Asexual Bisexual Gay man Heterosexual/ straight Lesbian/ Gay woman Pansexual Prefer to self-describe Prefer not to say Not known
Pregnancy and maternity
Required
What is your accommodation status?
Required
** None Owner Shared ownership (incl housing association) Private tenant Council tenant Homeless Supported accommodation (hospital, mental health, local authority)
What is your employment status?
Required
** None Employed Retired Student Unemployed
Relationship status
Required
** None Single Married Civil partnership Separated Divorced Widowed Not disclosed Cohabiting
Religion
Ethnicity
Required
** None 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 baground Black/ Black British: African Black/ Black British: Caribbean Black/ Black British: Any other Black/ Black British background 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
Dependants (e.g children)
Required
** None Children (at least one dependant child living in the same household) Adult (at least one dependant adult living in the same household) Dependants living in other household Other dependants None
First language
** None English as native speaker Non English native speaker (language support not needed) Non English native speaker (language support needed)
Have you previously been under the care of the SGS for previous treatment?
Required
** None Yes No
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
Do you have access to private space for a videocall with the SGS clinical team?
Required
Current location (if different from home address)
Are you a university student?
Required
** None Yes No
Are you serving or ex-military personnel
Required
** None Yes No
Homelessness
Required
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 service to share and receive necessary information with local authorities, NHS Professional Medical and NHS Healthcare services?
Required
** None Yes No
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.
