YouOKDoc and Clean Slate Clinic

Refer a patient to Clean Slate Clinic

For YouOKDoc clinicians. Please fill this in with the patient present: when you send it, you go straight to booking the patient's first clinical assessment with our clinical team. Private fees apply.

It takes about 10 minutes. Questions? Email services.uk@cleanslateclinic.com.

Fields marked * are required.

Your details

Your full name *

Your role (e.g. GP, nurse) *

Your email *

Your phone number *

Patient details

First name *

Last name *

Preferred name

Date of birth (DD/MM/YYYY) *

Patient's mobile number *

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

Street address *

Town or city *

Postcode *

NHS number

Gender

Sex registered at birthMaleFemaleOther

If other, please describe

Cultural and language information

Ethnic groupAsian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnic groupsWhiteOther ethnic groupPrefer not to say

Ethnic background (optional detail)

Preferred language

Interpreter required? *YesNo

GP information

Registered GP surgery

GP surgery phone number

Programme requested

Programme *Alcohol home detox: 12-month programmeBeyond Detox: 6-month programmeNot sure: assessment and adviceOther

If other, please describe

Clinical summary

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

Clinical summary *

Patient consent

I confirm that the patient has agreed to this referral to Clean Slate Clinic and to being contacted by the clinic about treatment.

Yes, the patient agrees to this referral *

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

Thank you! Your submission has been received!

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