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Referral agreement

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Gambling Disorder Treatment Provider Referral Agreement

The Problem Gambling Network of Ohio, in collaboration with Ohio for Responsible Gambling and the United Way of Greater Cleveland, vendor for the Ohio Problem Gambling Helpline, is updating the statewide treatment provider list for Gambling Disorder.

If you are a clinician that is Gambling Disorder treatment-qualified, currently able to provide services and would like to have your agency listed, please complete the brief form below.

...

1. Provider Information

First Name *

Last Name *

License # *

Agency *

Agency Address *

City *

State/Province *

Zip *

Work Email *

Personal Email (for PGNO use only) *

Work Phone *

Cell Phone (for PGNO use only) *

2. Please list all counties that you are able to provide gambling treatment services for *

3. I confirm that I hold the necessary credentials and am qualified to provide treatment services for Gambling Disorder

Provider's Name *

Date *

355 E. Campus View Blvd., Suite 285

Columbus, Ohio 43235

Phone (614) 750-9899

info@PGNOhio.org

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Referral agreement

Gambling Disorder Treatment Provider Referral Agreement

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