Compassionate Access Fund referral

Referrer details

Your details, so we can update you on the referral.

Referring organisation *

Your full name *

Your role

Your email *

Your phone number *

Client details

First name *

Last name *

Preferred name

Date of birth *

Mobile number *Australian mobile, e.g. 0412 345 678

Email addressIf the client has one

Street address *

Suburb or town *

Postcode *

Gender

Sex assigned at birth

MaleFemaleOther

If other, please describe

Cultural and language information

Country of birth

Preferred language

Interpreter required? *

YesNo

Does the client identify as Aboriginal and/or Torres Strait Islander? *

YesNoPrefer not to say

Healthcare information

GP name

GP clinic and phone number

Eligibility indicators

The Fund is for clients who are clinically suitable and actively help-seeking, but cannot access public funding or afford the full program fee. Tick all that apply.

If the client has had funding before, please give detailsRepeat access may be considered by exception.

Treatment type requested

Program *

Beyond Detox is for clients who want support to keep their goals after detox elsewhere, or after stopping.

If other, please describe

Clinical summary

A short summary of the client’s current situation and goals, and any relevant clinical information. Please include safety concerns, urgent needs and previous treatment.

Clinical summary *

Client consent

I confirm that the client has given informed consent for this referral to Clean Slate Clinic’s Compassionate Access Fund, agrees to be contacted by the clinic, and consents to the sharing and review of relevant information through appropriate channels to support coordinated care and the best health outcomes.

Yes, the client has given verbal or written consent

Referrer signature: type your full name *Typing your name signs this referral. It is dated automatically when you submit.

Refer a client to the Compassionate Access Fund

Referrer details

Client details

Cultural and language information

Healthcare information

Eligibility indicators

Treatment type requested

Clinical summary

Client consent

Subscribe

Company

The program

Contacts