REFERRAL FORM FOR PROFESSIONALS

This form is for health and care professionals or those working within a treatment service who are making referrals to EPIC Restart Foundation on behalf of people who have suffered gambling related harm and have been through treatment.

EPIC Restart Foundation is a UK charity that rebuilds lives after gambling harm. We are here to support individuals to restore confidence, self-belief and empower them to take the next steps in their journey of recovery.

By completing this referral, you are agreeing to the client being referred to our Restarting Lives 1-1 program and our EPIC Restart Community.

We do not provide treatment services or health care professionals.

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

State client detail's first

Date of birth

What gender does the client identify as?

Is the client abstinent from gambling? (optional)

YES

Does the client want to maintain an abstinence based recovery? (optional)

YES

Referrer Name

Referrer Contact Number

Referrer Email

Referrer Organisation

Relationship to Client (i.e. Therapist)

Please confirm the Client has consented to this referral

YES

Please confirm EPIC Restart Foundation has consent to contact using the following methods

Permission to leave Voicemail

Permission to send an SMS

Permission to send an Email

Does the client consent to EPIC Restart Foundation sharing information with the referring organisation?

YES

Please provide information about gambling treatment.

To your knowledge are there significant health conditions (physical or mental health), diagnoses, symptoms or prescribed medication that could prevent the client joining our programmes?

To your knowledge are there any risks relating to suicide, self-harm, aggression/violence to others, safeguarding children, domestic violence etc.

Please provide information your are aware of relating to social circumstances. For example, current employment, housing, any debt, family relationships etc

To your Knowledge, are there any other impulsive/compulsive behaviour(s). For example, watching porn, gaming, use of alcohol or drugs etc

Are you aware of any other services or organisations the client has been accessing.

Declarations

By clicking on this button and submitting this form I agree that the EPIC Restart Foundation can contact me and send me emails with information and updates about the Foundation’s activities in accordance with EPIC Restart Foundation’s privacy policy.

I have read and understood EPIC Restart Foundation's privacy policy

If you are a human, ignore this field

EPIC Restart Foundation is a registered charity no 1192907 Registered Office: Suite 2, Northern Diver Building, Appley Bridge, WN6 9AE