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Southern Gambling Service patient referral form

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.

Personal details

Required
Home address
Do you consent to being contacted by the service via your email address, telephone or SMS with clinic information? Required
Required
Required
Required
Required
Required
Required
Pregnancy and maternity Required
Required
Required
Required
Required
Required
Required
Required
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
Required
Required
Homelessness Required

Reason for self-referral

Required

History of gambling problems

Required
Required
Required

Other medical history

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.

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