Online Referral - SA Gambling Therapy

Date*

Name*

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?*

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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