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The National Centre for Gaming Disorders
National Centre for Gaming Disorders referral form

Back to The National Centre for Gaming Disorders

Need help urgently?

National Centre for Gaming Disorders referral form

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

First Name Required

Surname Required

Address (person being referred) Required

Address 1

Address 2

City

Country

State/Province

Postal Code

Telephone - Home

Telephone - Work

Date of Birth Required

Date

Gender (at birth/identity)

NHS Number

Religion

Mobile

Parent’s Mobile (if applicable)

E-mail / Fax

GP Required

Address (GP)

Address 1

Address 2

City

Country

State/Province

Postal Code

Telephone Number

Fax Number

E-mail

School/college

Address (School)

Address 1

Address 2

City

Country

State/Province

Postal Code

Named contact

Tel. No

Fax No

E-mail

Family Composition

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

Name of parent or carer

Relationship

Occupation/School

Living at home?

Age/Date of birth

Is this referral also for them?

Yes

Relationship

Name of second parent or carer

Occupation/School

Living at home?

Is this referral also for them?

Yes

Age/Date of birth

Who has legal parental responsibility?

Main language spoken by client Required

Main language spoken by parents/carer (if applicable)

Interpreter required and for whom

Language and dialect required

Professional Network

Mental health team involved? (e.g. CAMHS, CMHT)

Yes

Does the client have a formal or provisional diagnosis?

Yes

If yes, please give details

Name of Keyworker

Team

Telephone number

Is a social work team involved with the client?

Yes

Name of allocated social worker

Is the child on the Child Protection Register?

Yes

If yes, category/further information

Details of other agencies / professionals involved

Is the child looked after?

Yes

Name

Address

Contact number

Name

Address

Contact number

Ethnic group

Please select from the drop down list below

Disability

Is the referred person registered disabled?

Yes

Referrer’s Details

Date of Referral

Date

Name

Job Title

Agency

Address

Telephone Number

Consent for referral obtained from family?

Yes

Consent for referral obtained from young person?

Yes

Reason for Referral (please give a description of concerns) Required

Type of Gaming

Online

Offline

Tablet

Phone

Console

Computer

Main games used Required

Nature of gaming problem

Age gaming started

Time spent per 24 hours

Frequency per week

Age it became a problem

Missing school/work

Yes

School refusal

Yes

School/others noticing problem

Yes

Sleep disruption

Yes

Current needs and circumstances (please tick all that apply)

Mental Health

Physical Illness

Drug/Alcohol Use

Homeless

Outstanding legal

Current self-harm

Risk of causing physical harm to others

Risk of harm from others (e.g. bullying)

Physical disability

Other

Please give further information about any issues you have indicated

Referral Consent

I consent to details of the referral outcome being sent to the referrer

Yes

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

I consent to being contacted by telephone (landline)

I consent to being contacted by telephone (mobile phone)

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?

I consent to being contacted by e-mail

I consent to being contacted by letter

Signature (typed) Required

Date Required

Date

I agree to the privacy policy

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