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1. Question 1.

General Questions
Contact Details (most commonly we will contact you by email or by telephone. Please be assured we will always choose the method that is most confidential, safest and best suited to the matter at hand):

Required - Required.

Title: (Mr / Ms / Mrs / Dr)

Forenames

Surname

Date of Birth

Address 1

Address 2

City / Town

County

Postal Code

Email Address

Mobile Phone Number

*

2. Question 2.

Consent to text

Required - Required.

Yes

No

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3. Question 3.

Consent to leave voicemail

Required - Required.

Yes

No

*

4. Question 4.

Consent to email 

Required - Required.

Yes

No 

5. Question 5.

Additional Contact Details

Home Phone Number

Work Phone Number

*

6. Question 6.

Contact
From time to time we may wish to communicate with you by text message (e.g. to give you a password for any document we send by non-encrypted email). Are you happy for us to do so?

Required - Required.

Yes

No

7. Question 7.

Ethnicity

8. Question 8.

GP Practice

9. Question 9.

Do you consent for us to contact your GP?

Yes

No

Do you need a translator?

Yes

No

10. Question 10.

If Yes, what language?

11. Question 11.

Are you an affected other? ( Are you impacted or affected by someone else's gambling harms )

Yes

No

*

12. Question 12.

Where did you hear about our service?

Required - Required.