Referral Agreement

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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 be listed as a provider in your county, please complete this brief survey

Name *

Credentials *

Agency

County *

Address *

Work Phone *

Cell Phone (for PGNO use only)

Email *

I am interested in being listed as a provider for Gambling Disorder for the following:

Normal business hours providing outpatient treatment services.

Regional supervision to other Gambling Clinicians

I confirm that I hold the necessary credentials and/or Scope of Practice to provide treatment services for Gambling Disorder, attested by my completion of the necessary treatment hours, contact hours, and supervision required by the relevant accredited boards. *

Yes

Required

Submit

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