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Menu
Getting Help
Why Do People Gamble?
Do I Have a Gambling Problem?
Treatment that Works for Problem Gambling
Family and Friends
Youth
Online Referral
Real Stories
Roger's Story
Anne's Story
Rita's Story
Ruth's Story
Andrew's Story
Elsie's Story
Roy's Story
Cross Cultural
Testimonials
Our Business
Our Team
Current Projects
Annual Reports
Published Articles
Referral Form
News
Contact Us
FAQ
Links
Recently
Online Referral
Home
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Online Referral
Referral
Online Referral Form
Date
*
DD slash MM slash YYYY
Name
*
First
Last
Date of Birth
*
DD slash MM slash YYYY
What made you aware of this service?
*
Health Professional
Community/Family Support Worker
Friend/Family Member
Gambling Help Line
Media (Radio, TV, Internet)
Telephone Book
Gambling Venue Staff
Correctional Service
Information in Gambling Venue
Website (www.sagamblingtherapy.com.au)
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?
*
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:
I would prefer individual treatment.
I would prefer a group setting if it were available
I would prefer the first available option.
I have no preference and would be happy with either option.
Please use the drop-down box and select one of the following options.
Preferred Clinic
*
No Preference
Flinders Medical Centre
Elizabeth GP Plus
Is there any thing else you would like to add? Please input the type of gambling that you require treatment for in this field.
Captcha
Chase your dreams, not your losses
The Statewide Gambling Therapy Service is provided by the Southern Adelaide Local Network, and is funded through
SA Health
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