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 be listed as a provider in your county, please complete the brief form below.

Question Title

* 1. Provider Information

Name

License/License #

Agency

Agency Address

City

State

ZIP Code

Email Address

Work Phone

Cell Phone (for PGNO use only)

Question Title

* 2. I (provider) confirm that I hold the necessary credentials and have competency in providing treatment services for Gambling Disorder.

Provider's Name

Date