Apply for a place

Please complete the form below to apply for a place on the Gordon Moody residential treatment programme.

All application forms are retrieved Monday to Friday between 09:00 & 16:00. We try in all cases to contacted you within 48 hrs of your application being received.

However, any applications received during the weekend will not be retrieved until Monday 9am as may be longer.

Should you need urgent help please contact Gambling Therapy or GamCare

SERVICE USER DATA CONSENT FORM – REFERRALS/APPLICATION

Please make sure that you have read the Gordon Moody Association Privacy Information Notice which can be found on our website www.gordonmoody.org.uk.  or from the following links 

Privacy Information Notice - Support and Treatment Services

Personal Information Charter

Please tick the boxes below if you agree

Please select all that apply
(Please note that this is to ensure that the programme we offer is suitable for you. We will let you know before we do this, explain the reason(s) why we need the extra information, and obtain your specific written consent before requesting this information). I understand that an exception to this would be where the law requires GMA to share information, for example, if there was a concern that someone might be at risk of harm. We require a certain level of information to be able to process your application and provide you with appropriate treatment, and to ensure the safety of you and others. If you do not provide certain information or permit us to obtain this information from other services you are involved with, then we may not be able to process your application/provide treatment. For example, certain medical history, criminal history and proof of residency is required.
Information supplied to GMA may be used to provide statistical data for its funders. It may also be used for the improvement of service provision and the treatment of gambling addiction in general, for example, in research or training. However, no personal information will be used, and anonymity will be ensured at all times.

If you would like us to explain any of the information contained within this consent form, or if you would prefer to complete a paper version of this document then please contact us on 01384 241292 or via [email protected].

What happens if I change my mind about giving my consent?

You have rights in respect of the personal information that we hold about you, including the option to change your mind. 

You also have the right to: 

  • Ask us for access to information about you that we hold (Subject Access Request)
  • Have your personal data rectified, if it is inaccurate or incomplete
  • Request the deletion or removal of personal data where there is no compelling reason for its continued processing (Right to be Forgotten)
  • Restrict our processing of your personal data (i.e. permitting its storage but no further processing)
  • Object to us processing your data for the purposes of scientific/historical research and statistics

You can let us know that you have changed your mind or that you wish to exercise your rights under Data Protection law by contacting the Referrals Team in writing. Our contact details are: [email protected].

Please note, that withdrawing your consent may affect the nature and quality of the service that we may be able to provide to you.

How do I make a complaint?

If you have a concern or complaint about the way we are collecting or using your personal data, you should raise your concern with us in the first instance.  Please contact us by: 

  • Writing to Gordon Moody Association, 47 Maughan Street, Dudley, West Midlands, DY1 2BA
  • Calling us on: 01384 241292
  • Emailing:  [email protected].

If you remain unhappy with the way that your personal data has been handled by us, you could contact the Information Commissioner’s Office at https://ico.org.uk/concerns/

 

I am aware that I have rights in respect of the personal information that is held about me.  I understand that I can contact the Referrals Team if I would like further details about how my information is processed by the Gordon Moody Association.

 

Please type your full name

Programme Options


Section 1: Personal details 

Please use the "-" key to separate your DOB. For Example 01-01-1970

 If you are not a UK national please complete questions N1, N2 and N3

 State Benefit


Section 2: About your gambling

Every question must be answered


Section 3: Additional information

This information will be used to provide anonymous statistics or provide a better service for you. Information supplied in this section of the form may be used to provide statistical data for our funders and toward the understanding and improvement of service provision; and the treatment of gambling addiction in general. However, no personal information will be used and anonymity will be ensured at all times. The completion and submission of this form means that you agree to these terms and conditions of use:

What was your age when you started gambling?


What was your age when you started gambling?

Put a number '1' against the one you do most, '2' against the next, and so on.  You do not need to enter a number for those that do not apply.

 Bookmakers

Bingo Hall

Casino

Live Events

Adult entertainment centre (18+Arcade)

Family entertainment centre (Arcade)

Pub

Online (Mob/PC/Tab)

Miscellaneous

Private Members Club

£

What is the average (approximate) amount spent on gambling in the past year and your income.  Example: If your income was £100 per week and you spent £150 per week enter £100 in the income box and £150 in the gambled box.

Per week:

Per month:

Total in a year


Section 4: Ethnic origin

The Gordon Moody Association recognizes that certain groups and individuals are discriminated against on the basis of their race, age or ethnic origin, marital status, nationality, HIV status, gender, sexual orientation and disability.  The Association is committed to breaking this and any other cycle of discrimination. Please help us to do this by ticking the boxes below that you feel describe you in the most accurate way.

 Choose ONE section from A to E, then tick the appropriate box to indicate your ethnic group

Supporting you

Supporting you

"I'm very lucky to be here with so many other addicts who are positive and want to change and achieve recovery" Learn about our programme