Online Referral

Date*

Is this referral in relation to yourself or someone else?*

If this referral is for someone else, please provide your details within the text box below:

Please provide your name, relationship to the person being referred, best contact details (ie telephone number, email) and organisation/title if applicable.

Name*

(The below fields are for details of the person being referred.)

First Last

Date of Birth*

What made you aware of this service?*

Have you attended Statewide Gambling Therapy Service before?*

Yes
No

Are you of Aboriginal and/or Torres Strait Islander descent?*

Yes
No

Is English your first language?*

Yes
No

If no, what is your primary language?

Address*

Street Address Suburb State Postcode

Phone*

E-mail address

GP (do you have a GP that is aware of the issue?)*

Medicare number (this is a free service, you will not be charged)*

Medicare Expiry Date*

Have you ever been a patient at Flinders Medical Centre before?*

Yes
No

Are you okay with us sending correspondence (eg. appointment letters) to your address?*

Yes
No

Are you okay with us sending you text reminders about appointments?*

Yes
No

When is the best time for us to reach you about booking in an appointment?*

Please note our opening hours are Monday to Friday between 9am to 5pm. Our service also closes on public holidays. Once we have received your referral, we will be in contact within 2 business days. Please get in touch with us if you have not heard from us after this time frame on 8204 4779.

SGTS provides flexible options for treatment - delivered face to face, on the phone or through a telehealth video conference. How would you like to meet with your therapist for your first appointment? // Please select one:*

Phone Call
Video Call (via Health Direct)
Face to Face

At times treatment is available in a small group setting please indicate your preference:

Please use the drop-down box and select one of the following options.

Preferred Clinic*

Is there any thing else you would like to add? Please input the type of gambling that you require treatment for in this field.

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Referral Form