Torrens University referral | Clean Slate Clinic

Referrer details

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

Torrens campus or clinic *

Your full name *

Your role (e.g. counsellor, student clinician) *

Your email *

Your phone number *

I have completed the Clean Slate Clinic referral training *

Student details

First name *

Last name *

Preferred name

Date of birth (DD/MM/YYYY) *

Student's mobile number *Australian mobile, e.g. 0412 345 678

Student's email address *The booking confirmation is sent here

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 student identify as Aboriginal and/or Torres Strait Islander? *

YesNoPrefer not to say

Aboriginal and Torres Strait Islander students can also yarn with our Aboriginal and Torres Strait Islander team at yarn@cleanslateclinic.com. You can still book the first assessment below.

Healthcare information

GP name

GP clinic and phone number

Treatment type requested

Program *

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

If other, please describe

Clinical summary

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

Clinical summary *