Online Application

To apply for one of our places please complete our online form below. Once this is submitted a member of our referrals team will be in touch to arrange completion of the application and an assessment to help review your case and provide you with a treatment plan to match your needs.

Are you completing this form on behalf of an applicant, and if so are they present?

Myself On behalf of someone who is present On behalf of someone who is not present

All of the following questions are about the person who needs treatment.

Forename*

Surname*

Date of Birth*

Please provide us with the best telephone number to contact you on*

We need to have a telephone number that we can telephone you on to progress and/or complete your application. If you don’t have a number then enter the following number into this field – 01384 241292. Once you have completed this application form, use this number (01384 241292) to call us and discuss your application.

Email Address*

Confirm Email Address*

Address*

Postcode*

Contact Permissions*

Please indicate any and all methods of communication that you are happy for us to use to make contact with you about your application to us for treatment. We will never use any of these methods for general marketing purposes.

I am happy for Gordon Moody to leave a voicemail on the telephone number provided above

I am happy for Gordon Moody to send me an email on the email address provided

I am happy for Gordon Moody to send me a text message

I am happy for Gordon Moody to send me a WhatsApp

I am happy for Gordon Moody to send me a letter

Let us know of any specific contact preferences that you have such as the best/worst time to call, etc.

By ticking the I am happy to proceed check box you agree that Gordon Moody can save your personal/contact details and may use them to contact you to process your application for treatment or as part of our duty of care to you. Your personal details will be kept by us but will never be disclosed to any third party for any reason and will only be collected, used and stored in line with our privacy policy. Clicking ‘NEXT’ is confirmation that you have read and understood this statement and are happy to proceed with your application.

I am happy to proceed

Gender/Identity*

Self-Described Gender Identity*

Sex at Birth*

Sexual Orientation

Self-Described Sexual Orientation*

Ethnic Origin

Do you consider yourself to be disabled?

yes no

Are you registered disabled?

yes no

Is there anything else you would like to tell us about yourself or your gambling?

We occasionally have cancellations for assessments. Are you happy for us to contact you at short notice so we can undertake your assessment sooner?

yes no

Gordon Moody

Find out more about Gordon Moody