You are welcome to email or call us for a consultation before making a referral.

Our phone number is: 020 7381 7722

If you are making this referral on behalf of someone else, please ensure they have agreed to it

CNWL (like other NHS organisations) routinely maintains records of your contact details, information about your treatment and shares relevant details with other services that provide care to you, on a need to know basis. These services (like CNWL) have a legal responsibility to safeguard your data. For more information please visit the website or contact the service to request a copy of the information booklet. Please inform the service if you have any concerns about this.

Details of the person being referred

Address (person being referred) Required
Address (GP)
Address (School)

Family Composition

Please indicate if parents/carers would like to access support at the clinic

Is this referral also for them?
Is this referral also for them?

Professional Network

Mental health team involved? (e.g. CAMHS, CMHT)
Does the client have a formal or provisional diagnosis?
Is a social work team involved with the client?
Is the child on the Child Protection Register?

Details of other agencies / professionals involved

Is the child looked after?

Ethnic group


Is the referred person registered disabled?

Referrer’s Details

Consent for referral obtained from family?
Consent for referral obtained from young person?
Type of Gaming

Nature of gaming problem

Missing school/work
School refusal
School/others noticing problem
Sleep disruption
Current needs and circumstances (please tick all that apply)

Referral Consent

I consent to details of the referral outcome being sent to the referrer
By what method would you like to be contacted by a member of the gaming clinic staff?

One or both of the following methods of communication must be ticked to enable us to send written communication

By what method would you like to be contacted by a member of the gaming clinic staff?