CNWL National Problem Gambling Clinic - Referral Form

1. Client Details
Date of referral: / Self referral? Yes* No
Is this a re-referral? Yes No
Title: / First name: / Surname:
Also known as:
Age: / Date of Birth:
Address:
Postcode:
Home phone: / Mobile: / E-mail:
NHS Number:
Where did you hear about the CNWL National Problem Gambling Clinic?
Local Authority / Borough of Residence:

*If self referral please ignore section below and move to section 3. 3

2. Referrer’s Details
Referral Agency: / Referrer’s Name:
Address:
Postcode:
Telephone: / Fax: / E-mail:
Main reason for referral:
Has the client accessed this type of service before? / Yes: / No:
Where: / Date:
IMPORTANT NOTE: REFERRALS FROM EXTERNAL AGENCIES
All referrals from external agencies must be accompanied by a recent report highlighting information that may be relevant to the assessment, particularly around difficulties and risk. Please note that the client will not be offered an assessment until this information is received from the referrer.
3.  Client’s Personal Details (circle or mark as appropriate)
Consent: We ask for the following information about you to help us monitor and improve our services. We request your consent to contact your GP and any other agencies involved in your treatment. When you attend your appointment you will be asked to give consent for CNWL to contact other agencies. See confidentiality form at your first appointment for more information about this. However, please contact us to discuss this further before your first appointment if you have concerns.
Gender / 01 - Male 02 - Female
03 - Other / Marital Status / 01 - Single 03 - Cohabiting 05 - Separated
02 – Married 04 – Divorced 06 - Widowed
Sexual Orientation / 01 – Bi-sexual 02 – Gay 03 – Heterosexual 04 – Lesbian 05 – Not Known 06 – Other
07 – Preferred not to say
Children / Does the client have any children under 16? 01 - Yes 02 - No 03 - Would rather not say
If so, how many children live with the client at least part of the time?
Is the client pregnant? 01 - Yes (state due date) 02 - No 03 - Not Applicable
GP Details / Is the client registered with a GP? Yes No
GP Name:
Address:
Postcode:
/ Telephone:
Ethnicity
(Circle or mark one option only as appropriate) / White
01 – British
02 - Irish
03 - Any Other White Background – please state:
Mixed
04 - White & Black Caribbean
05 - White & Black African
06 - White & Asian
07 - Any Other Mixed Background – please state: / Asian or Asian British
08 - Indian
09 - Pakistani
10 - Bangladeshi
11 - Any Other Asian Background – please state:
Black or Black British
12 - Caribbean
13 - African
14 - Any Other Black Background – please state:
Other Ethnic Groups
15 - Chinese
16 - Any Other Ethnic Group – please state:
Religion/Belief
Nationality/Country of Origin / Main Language Spoken
Interpreter Needed? / Yes / No
Special Needs / (Please tell us whether the client has any disability or special needs that we should be aware of)
Main Occupational Status
(Circle or mark one option only as appropriate) / 01 - Employed (full-time) 07 - Main family carer (child/adult)
02 - Employed (part-time) 08 - Retired
03 - Self-employed/own business 09 - Other – e.g. Doing unpaid / voluntary work
04 - Unemployed (looking for work) 10 - Other – e.g. Permanently unable to work
05 - Student (full-time) due to long- term sickness or disability
06 - Student (part-time) 11 - Other – e.g. On a Government training scheme
12 - Other – please state:
Job Title
(Circle or mark one option only as appropriate) / 01 - Transport and logistics 11 - Engineering and science
02 - Sales and marketing 12 - Education and training
03 - Retail and food services 13 - Building, construction and property
04 - Public service, safety and security 14 - Office and administration
05 - Outdoor and other 15 - Media and language
06 - Manufacturing and production 16 - IT and telecoms
07 - Manual and general 17 - Hospitality, sports and leisure
08 - Management and executive 18 - Arts, craft and entertainment
09 - Legal and financial 19 - Not applicable
10 - Health, care and community 20 - Other – please state:
Income Type
(Circle or mark as appropriate) / 01 - None State Benefits: 07 - Income Support
02 - Salary 08 - Jobseekers Allowance/Employ. Support Allowance
03 - Self-employed 09 - Invalidity
04 - From family or partner 10 - Disability Living Allowance
05 - Pension 11 - Attendance Allowance
06 - Private source 12 - Other – please state:
Income
(Please estimate your income either on an annual or monthly basis / 01 - Annual / £ / 02 – Monthly / £
03 - Not applicable – no source of income
04 - Income irregular – unable to estimate
05 - Would rather not say
Accommodation Type
(In which of these ways do you occupy this accommodation?) / 01 - Buying it with the help of a mortgage or loan
02 - Own it outright
03 - Pay part rent and part mortgage (shared ownership)
04 - Rent it
05 - Tied accommodation (e.g. where the accommodation goes with your job)
06 - Live here rent-free (including rent-free in relative’s/friend’s property)
07 - Homeless
Qualifications
(Please select the highest qualification that you have) / 01 - Higher degree
02 - Degree level qualification or equivalent
03 - Professional qualification below degree level (e.g. teaching, nursing)
04 - ‘A’ Levels or equivalent
05 - GCSE / ’O’ Levels or equivalent
06 - No formal qualifications
07 - Qualifications other than those listed above
4. Identification of Problem Gambling Issues
Details of issue(s) / Frequency / Amount
Client’s view of main problem and expectations of the service
Identification of related issues, specific risk and priority need. Please indicate if the client has issues in relation to any of the following (circle or mark as appropriate)
·  Mental Health *
·  Physical Illness*
·  Young Person
(Under 18)
·  Pregnant woman
·  Child/ren may be
in need
·  Drug Use
·  Homless
·  Oustanding legal** / ·  Current self harm
·  Risk of causing physical harm to others
·  Physical disability
·  Alcohol Problems
·  Probation
·  Social Services
·  Other – please describe / Comments:
* Current ill-health requiring medication or intervention
** Please give details, i.e. court date/warrant notice
5. Severity indicators
On how many days in the last 30 days have you gambled?
What is your estimate of the total amount of money that you have lost in the last 30 days? Please include only money that is yours, or obtained from other sources; do not include winnings in this total.
Gambling products
Please indicate what forms of gambling you have used in the past 30 days and on how many days you would have used this product?
Product / Yes/No / Estimated days used
Lotteries or scratch-cards / Yes/No
Gambling on the internet using a computer / Yes/No
Gambling on the internet using a mobile phone / Yes/No
Interactive television gambling / Yes/No
Gambling over the telephone / Yes/No
Gambling in a casino / Yes/No
Sports betting in a bookmakers premises / Yes/No
FOBT machine use in bookmakers (e.g. roulette, poker, blackjack) / Yes/No
Playing bingo / Yes/No
Gambling at a sports event / Yes/No
Gambling on gaming machines (‘fruit’ machines) / Yes/No
Other (please list) / Yes/No
How troubled or bothered have you been in the past 28 days by these gambling problems? (Please circle one)
Not at all / Slightly / Moderately / Considerably / Extremely
0 / 1 / 2 / 3 / 4
In the last 28 days what proportion of the time that you consider to be free to yourself would you spend on
gambling? This includes actual gambling, thinking about gambling and activities relating to gambling, such as
managing debts:
None / Not very much / Some of my free time / Most of my free time / All of my free time
0 / 1 / 2 / 3 / 4
Over the last 2 weeks how often have you been bothered by the following symptoms?
Not at all
0 / Several days
1 / More than half the days
2 / Nearly every day
3
1. Little interest or pleasure in doing things.
2. Feeling nervous, anxious or on edge.
3. Feeling down, depressed or hopeless.
4. Not being able to stop or control worrying.
Client Consent (Please tick or mark all that apply) / YES / NO
I consent to this referral being made
I consent to details of the referral outcome being sent to the referrer
I consent to details of the referral outcome being sent to my GP
By what method would you prefer to be contacted by a member of Gambling Clinic staff?
(Please tick or mark all that apply)
I consent to being contacted by telephone (landline)
I consent to being contacted by telephone (mobile phone)
I consent to being contacted by e-mail
I consent to being contacted by letter
Signed (Referrer)
Signed (Client) / Date
Date
From time-to-time, you may have the opportunity to take part in research projects that are undertaken in the Gambling Clinic. We believe that research is integral to improving our service and understanding more about gambling. If you are invited, you will be informed about the project and given time to consider whether you want to take part. Please be reassured that your decision will not affect your clinical treatment with us. To find out more about how you can be involved in exciting research projects at the Clinic, please speak to a member of staff.