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The National Centre for Gaming Disorders
Make a referral for you or a family member

Back to The National Centre for Gaming Disorders

Need help urgently?

Make a referral for you or a family member

Referral Form

For gamers, family members, partners & carers

Is this a self-referral? Required

Game users details (if consented to referral)

First Name Required

Surname Required

Known as Required

Address Required

Address 1

Address 2

City

Country

State/Province

Postal Code

Email Required

Phone number Required

Date of birth Required

Date

Gender Required

Marital Status

Ethnicity

Religon

Sexuality

Language

Interpreter required Required

GP Surgery Required

GP name Required

Address Required

Address 1

Address 2

City

Country

State/Province

Postal Code

Main carer, family member or partner details (If this is a self-referral for an over 18, this is optional)

First Name

Surname

Relationship

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Phone number

Ethnicity

Gender

Marital Status

Religon

Occupation

Language

Interpreter required

GP Surgery

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Additional Carer or family member details

First Name

Surname

Relationship

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Phone number

Date of birth

Date

Gender

Marital Status

Ethinicity

Religon

Occupation

Language

Interpreter required

GP Surgery

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Please complete section below with the names of the persons the referral includes and indicate they are aware & consent to the referral

Please note: the service can still offer support to family members and partners of people who do not wish to be referred for their games use.

Consent

Name Required

Referral Required

Consent given to referral Required

Consent given to referral

Name

Referral

Consent given to referral

Name

Referral

Consent given to referral

Name

Referral

Consent given to referral

Please complete section below with the details of the referrer, please leave this section blank if a self-referral

Referrers details

Name

Title

Phone number

Email Address

Organisation

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Please complete section below with a brief description of the reasons for the referral

Reasons for referral

Please complete sections below with details of the persons game use

Game use information

Games played

Please tick the boxes below to indicate all devices used:

Online

Offline

Console

Computer

Tablet

Mobile phone

Hours played per day in week

Hours played per day at weekend

Days played per week

Age use began

Age use became problem

Impact of games use

Education or work refusal/days missed

Yes

Education or work performance

Yes

Aggression

Yes

Personal hygiene

Yes

Sleep disturbance

Yes

Violence

Yes

Food intake

Yes

Relationships

Yes

Physical Health

Yes

If yes, please specify

Anxiety (including social anxiety)

Yes

Depression

Yes

Other (please specify)

Please complete the sections below with details of any current diagnoses (mental health)

Current needs & circumstances

Please tick all that apply below and give details in the free text box

Mental Health

Physical illness

Physical disability

Current self-harm

Harm from others

Harm to others

Alcohol or drug use

Homeless

Criminial justice system

Diagnosis (list all)

Please give details & include any diagnoses awaiting to be confirmed

Please complete the sections below with details of any professionals, services or agencies that currently support the game users care

Professional, service or agency

Name

Title

Phone number

Email Address

Organisation

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Professional, service or agency

Name

Title

Phone number

Email Address

Organisation

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Professional, service or agency

Name

Title

Phone number

Email Address

Organisation

Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Please complete the section below with the person to confirm their consent to share information with the referrer and client chosen methods of contact

Please note: the service will require at least one method for written contact