Agency Client Referral Form

Arizona Problem Gambling Peer Support Program Agency Client Referral Form

Submit a referral for peer support services. All services are free and confidential. Contact us at 1-833-404-9526 or referrals AZReferral@dezezerve.info for assistance.
SECTION 1: Referring Agency Information
Agency Name*
Contact Person Full Name*

First NameLast Name
Title/Position*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Agency Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Relationship to Client*

Healthcare ProviderSocial ServicesCommunity OrganizationLegal ServicesFinancial CounselingFamily MemberSelfOther
SECTION 2: Client Information

(Complete as much as available)
Client First Name*
Client Last Name
Preferred Name/Nickname
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleNon-binaryPrefer not to say
Client Phone Number*
Please enter a valid phone number.
Client Email Address
example@example.com
Client Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
County
ZIP Code
Primary Language

EnglishSpanishOther
Is an interpreter needed?

YesNo
Is TTY/TDD needed?

YesNo
Best Contact Method

PhoneTextEmailMail
Best Contact Time

MorningAfternoonEveningWeekdaysWeekends
SECTION 3: Service Preferences & Needs
Type of Support Requested (Select all that apply)*

One-on-One Peer SupportGroup Support MeetingsFamily Support/EducationResource Navigation (financial, housing, legal)Not sure – would like to discuss options
Preferred Modality*

Virtual (video)PhoneIn-personNo preference
Urgency Level

Standard (contact within 1 business day)Urgent (contact within 24 hours) – Please call 1-833-404-9526Crisis – Please call National Problem Gambling Helpline: 1-800-522-4700
Currently Receiving Clinical Treatment for Gambling?*

Yes (please specify provider)NoUnknown
If yes, please provide provider name
Date (Client/Guardian Authorization)

MonthDayYear
Date
Date (Information Release Authorization)

MonthDayYear
Date
SECTION 4: Referring Provider Notes (Optional)
Reason for Referral / Brief Context
Safety Considerations*

NoneSuicidal ideationHomicidal ideationDomestic violenceOther
Special Accommodations Needed
Should be Empty:

Arizona Problem Gambling Peer Support Program Agency Client Referral Form

SECTION 1: Referring Agency Information

SECTION 2: Client Information

SECTION 3: Service Preferences & Needs

SECTION 4: Referring Provider Notes (Optional)