E-Referral

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- Step 1 of 4

Please select query type *

Full Name *

First

Last

Gender *

Date of Birth *

Province *

Marital Status *

Age *

ID Number *

Contact Number *

Level of Education *

Name of the Referring Person *

First

Last

Contact Number *

Email *

Province *

Designation *

Name of the Person being Referred *

First

Last

Contact Number of the party being referred *

Problem Gambler

Which of the following conditions do you suffer from? *

Have you been diagnosed by a medical practitioner? *

Are you on any medication *

Describe your medication *

Which of the following physical condition do you have ? *

Did you gamble during your self-exclusion? *

Self Exclusion

Type of Self Exclusion *

When did you exclude yourself from gambling? *

What are you reasons for requesting counselling?

Why did you self-exclude yourself?

Were you under any alcohol/drug influence while applying for exclusion? *

What is the relationship between you and family member who gambles? *

Have you made the person aware about the impact of their gambling on you ? *

How is it affecting you? *

How many years have you been affected? *

Did the person consent to be referred?

Available 24 hours a day, seven days a week, the SARGF Counselors offer professional counselling services over the phone, as well as referrals for face-to-face treatment throughout the SARGF country-wide treatment professional network – absolutely FREE of charge on 0800 006 008 or WhatsApp on 071 515 0429

Discliamer, displayed here

Where did you learn about gambling?

Do you gamble more than you could afford?

Do you spend most of your time thinking your next gambling activity?

After you have lost money do you walk away, or you think of how you can recover your money

Do you think that your gambling is affecting your personal life ?

Have you ever attempted to stop gambling ?

Have you borrowed money from anyone to gamble?

Which of the following best describe your gambling activity (5Ps)

1. Describe symptoms you are experiencing resulting to your decision to seek professional help (*Presenting problem*) ?

2. Which of the factors led to you developing a problem "gambling problem" these may include genetics, life events or temperament/mood (*Predisposing factors*)?

3. What are the events or stressors that trigger/activates your problem? (*Precipitating factor*)?

4. What are the factors that makes the problem continue even though it is hurting you ? (*Perpetuating factors*)?

5. What factors can be used to reduce the problem and promote healthy functioning (*Protective factors*)

Do you consume alcohol?

How often do you have a drink containing alcohol? *

How many drinks containing alcohol do you have on a typical day when you are drinking? *

How often during the last year have you found that you were not able to stop drinking once you had started? *

Do you consume drugs? *

How often do you use drugs other than alcohol? *

Do you use more than one type of drug on the same occasion? *

How often are you influenced by heavy drugs? *

Are you suicidal? *

Are you seeing a psychologist or psychiatrist? *

Do you have Hope for your future? *

Do you have suicide plan? *

What currently prevents you from taking your life *

Have you ever attempted taking your own life?

Financial Literacy

What is your employment status:

What is your source of income:

Do you have debt? If so, how much debt do you have?

Are you familiar with financial literacy? *

Do you have a clear understanding of your current financial situation? Yes/No *

What do you understand about budgeting? The importance of budgeting? (A bit explanation of what client understands) *

Do you understand the risks of being in debt? *

Do you have a strategy for managing your debt? *

Do you track your expenses and review your financial spending? *