Referral type
* Required
Are you an NHS registered healthcare professional / clinician?
* Required
Yes
No
Are you a private or third sector registered healthcare professional / clinician?
* Required
Yes
No
Patient details
Patient’s full name
* Required
Previous surnames (if applicable)
Patient's address
* Required
Patients email
* Required
Mobile or landline phone number
* Required
Date of Birth
* Required
NHS Number
* Required
Gender
* Required
Is your gender identity the same as your sex recorded at birth?
* RequiredYes No Prefer not to say Not known
Sexual orientation
* RequiredAsexual Bisexual Gay man Heterosexual/ straight Lesbian/ Gay woman Pansexual Prefer to self-describe Prefer not to say Not known
Pregnancy and maternity
* Required
Not applicable
Currently pregnant
Currently breastfeeding
Given birth in the last 26 weeks
Prefer not to say
Not known
What is the patient's accommodation status?
* Required** None Council tenant Homeless Owner Private tenant Share ownership (incl. Housing Association) Supported accommodation (hospital, mental health, local authority)
What is the patient's employment status?
* Required** None Employed Retired Student Unemployed
Marital status
* RequiredSingle Married Civil partnership Divorced / dissolved Civil Partnership Widowed / surviving partner in Civil Partnership Not disclosed Separated Cohabiting
Religion
* Required
Ethnic background
* RequiredArab 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
* RequiredChildren (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
* RequiredEnglish native speaker Non-English native speaker (language support not needed) Non-English speaker (language support needed) Other (special assistance required)
Known to the SGS from previous treatment?
* Required
Yes
No
Next of Kin detail (include name, relationship and mobile number)
* Required
GP name, address and phone number
* Required
Does the patient have access to the internet for virtual (TEAMS) meetings?
* Required
Yes
No
Patient’s current location (if different from home address)
Is the patient a university student?
* Required
Yes
No
Is the patient a serving or ex-military personnel?
* Required
Yes
No
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 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
Yes
No
Are there safeguarding concerns around this person? If so, please detail below.
* Required
Consent
Has the patient given consent to this referral?
* Required
Yes
No
Has the patient given consent for SGS to share information with local authorities, GP and NHS healthcare professionals?
* Required
Yes
No
Has the patient given consent to be contacted by the SGS via e-mail, telephone and SMS?
* Required
Yes
No
Consent taken by
* Required
Date and time consent gained
* Required
Is there any specific requested restriction on sharing information?
* Required
Yes
No
If there is a specific restriction, please provide details.
Referrer details
Date of clinical assessment
* Required
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
