Referral Form for Professionals

This form is for health and care professionals making referrals into Gordon Moody
on behalf of people with gambling addiction problems.

If you are a member of the public looking for support, please visit our website for more
information at www.gordonmoody.org.uk

Fields marked with an * are required

Service user details

Service user details

Full Name *

Date of Birth *

Address

Post Code *

Gender *

Gender Other, please specify:

Preferred contact number(s) *

Divider

Referrer details

Referrer details

Name *

Contact number

Organisation *

Address

Post Code

Email *

Relationship to service user (i.e. General Practitioner) *

Please confirm the service user has consented to referral *

Please confirm Gordon Moody has consent to contact using the following methods

Permission to leave Voicemail
Permission to send an SMS
Permission to send an Email

Divider

Information about gambling *

Health *

Risks *

Social circumstances *

Any other impulsive/compulsive behaviour(s) *

Other involved services/organisations *

Referral Form for Professionals

Gordon Moody

Find out more about Gordon Moody