Clean Slate Suitability Test
Completing this form will enable us to give you an indication of whether the Clean Slate Clinic may be a suitable service for you - it does not replace assessment by a qualified health practitioner.   We will contact you within 3 working days to confirm your suitability and advise on next steps.

Please note we do not routinely operate outside of normal working hours.  If you need directing to an appropriate service now, please contact healthdirect on 1800 022 222 or healthdirect.gov.au.  If you are feeling suicidal or in crisis Lifeline provide 24 hour crisis support on 13 11 14 and if you are feeling acutely unwell please contact you're out of hours GP or nearest Emergency Department.

By providing your e-mail address below, you are agreeing to the use of this e-mail for correspondence with Clean Slate Clinic.
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Email *
Consent for us to your data *
I consent to my data being collected and stored by Applied Recovery Co. for the purpose of assessing my suitability to take part in the Clean Slate Clinic, for providing updates regarding their service  and, in  anonymised form, for the purposes of health research.
Required
First Name *
Last Name *
Date of Birth *
MM
/
DD
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YYYY
Gender *
At this time, Medicare does not support options other than Male or Female for their electronic medication prescription software. If you select Other or Unknown below, our team will be in contact with you to discuss a suitable solution.
Pronouns *
At this time, Medicare does not support options other than Male or Female for their electronic medication prescription software. If you selected Other or Unknown above, our team will be in contact with you to discuss a suitable solution. Your pronouns below will be added to your medical record, should you choose to proceed, so we can address you correctly.
How did you hear about Clean Slate Clinic?
How many days per week do you drink? *
How much do you drink per session? *
Do you suffer with: *
Tick those which apply
Required
Do you have a history of fits, seizures or hallucinations? *
Do you use illicit drugs *
Have you been through a clinical alcohol detox service before? *
Do you have close friends and family  or other support? *
Do you have any employment, housing, finance or legal issues? *
Are you strongly motivated to change your drinking habits? *
Do you live in Australia? *
What postcode do you live in? *
Do you have access to a phone or laptop, and WiFi connection? *
What name would you like us to use when we contact you? *
What mobile number can we use to contact you? *
Please use an Australian mobile phone number starting with 04 or +61
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