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


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

Please tick all of the following that apply.


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


Data Collection

Information supplied in these application forms 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 assured at all times. 

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