Young People's Gambling Harm Prevention Programme

I am a...? *

Parent
Family member/Friend
Professional
Young person

I am requesting help for? *

Myself
My child/dependant
Unsure

I am requesting help for? *

Myself
Friend/Family member
Unsure

I am requesting help for? *

Myself
A young person/adult I support
Unsure

I am requesting help for? *

Myself
Friend/Family member
Unsure

What is the concern? *

Gambling
Gaming
Crypto
Other

My full name *

First

Last

My date of birth *

My postcode *

Do you agree for this referral to be followed up by the Young People’s Service? (Please note, if you select no, we cannot contact the young person) *

Yes
No

My preferred method of contact *

Email
Telephone
Text message
Voicemail

My email *

My phone

Is the parent/guardian of the person you’re referring aware of this referral (Select N/A if you’re referring an adult) *Please note, if you select no, we cannot contact the young person *

Yes
No
N/A

Do I have consent from the person I’m referring? (Please note, if you select no, we cannot contact the young person) *

Yes
No

Young Person/s full name *

First

Last

Is the parent/guardian of the person you’re referring aware of this referral *

Yes
No

Please provide details *

Name of Person being referred *

Young Person/s date of birth *

Young Person/s postcode *

Young Person/s preferred method of contact *

Email
Telephone
Text message
Voicemail

Young Person/s email *

Young Person/s phone number

I acknowledge that the Young People's Service will speak to me before contacting the client? *

I agree

My contact details *

My relationship to the person I am referring *

My full name *

Name of my workplace *

My professional role *

My full name *

My preferred method of contact *

Email
Telephone
Text message
Voicemail

My email *

My phone *

My postcode *

Where/How did you hear about us? *

Please specify *

Please specify which social media channel *

What outcome would you like from this referral? *

Advice/Guidance
Direct Intervention

Please tell us a bit about how we can help? *