Early Recovery Coaching and W.E Self Referral

Please complete the form below if you would like to access Early Recovery Coaching or our Woman. Empowered Programme.

We will then be in touch to talk through the next steps.

Early Recovery Coaching and W.E Referral Form

Date of birth

Man

Non-binary

Woman

Prefer to self describe below

Self-describe gender: (optional)

Asian or Asian British

Black, Black British, Caribbean or African

Mixed or multiple ethnic groups

White

Other ethnic group (please specify below)

Prefer not to say

If you selected 'other ethnic group' above, please specify below (optional)

I'm reaching out for help for the first time (or haven't previously received treatment for gambling addiction)

I'm looking for long term support after active addiction (have previously received treatment for gambling addiction)

Text message

Phone

Yes

Morning

Afternoon

Evening

Anytime

I have read and understood EPIC Restart Foundation's Terms and Conditions

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EPIC Restart Foundation is a registered charity no 1192907 Registered Office: Suite 2, Northern Diver Building, Appley Bridge, WN6 9AE