Restarting Lives Self Referral

Thank you for your interest in our Restarting Lives programme. Please complete the form below and a member of the team will be in touch to talk you through the next steps.

Restarting Lives Self Referral

Date of birth

Gender: How do you identify?

Man

Non-binary

Woman

Prefer to self-describe, below

Self-describe gender (optional)

Which race or ethnicity best describes you?

Asian or Asian British

Black, Black British, Caribbean or African

Mixed or multiple ethnic groups

White

Other ethnic group (please specify below)

Prefer not to say

If you selected 'other ethnic group' above, please specify below (optional)

Where are you in your recovery journey?

I'm reaching out for help for the first time (or haven't previously received treatment for gambling addiction)

I'm looking for long term support after active addiction (have previously received treatment for gambling addiction)

Declaration

I have read and understood EPIC Restart Foundation's Terms and Conditions

EPIC Restart Foundation Terms and Conditions

If you are a human, ignore this field

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