Welcome - you're in the right place.

This comprehensive assessment (about 20–30 minutes) helps us understand your context and tailor care safely. A nurse will review your answers in advance of your booked appointment and discuss them with you.

Use the arrows to move forward/back — your progress auto-saves if you leave and return. Your information is confidential and only seen by our care team.

Please specify an answer

What is your legal name?

ℹ️ Our records need to match your Legal ID in order for us to provide medical services to you

First Name

Please specify an answer

Surname

Please specify an answer

What is your address?

ℹ️ Healthcare services are required to capture this information

Flat/House Number & Street

Please specify an answer

Town / City / Area

Please specify an answer

Postcode

Please specify an answer

What type of accommodation is this?

ℹ️ Healthcare services are required to capture this information

Please choose an option

Can we send packages to this address?

ℹ️ We will need to send items to you as part of your care with us

Please choose an option

👍

Yes

👎

What address can we use?

ℹ️ We need an address we can send packages to

Address

Please enter a valid address

What is your gender?

ℹ️ Healthcare services are required to capture this information

Male

Female

Other

Are you pregnant?

ℹ️ This information will help us to tailor services appropriately to you

Yes

Unsure

What is your ethnicity?

ℹ️ Healthcare services are required to capture this information

Please select the option that best describes your ethnic group or background (choose one)

Do you face additional barriers to accessing care?

ℹ️ We will use this information to make our services as accessible to you as possible

Please select the option that best describes your ethnic group or background (choose one)

Have you been a primary caregiver or living with children in the past 4 weeks?

ℹ️ We ask this question to plan your care safely and support your family. This won’t affect access to treatment.

Please choose all options that apply

Yes, with children under 5 years old

Yes, with children 5-15 years old

What is your current employment status?

ℹ️ Healthcare providers are recommended to ask this question

Please choose the option that best describes your current status

What is your occupation?

ℹ️ This helps us to understand which Industries are most in need of support

Industry

What is your occupation / job title

Please specify an answer

Who is your GP?

ℹ️ With your consent we will keep your GP updated on how your care is progressing

GP First Name

Please specify an answer

GP Last Name

Please specify an answer

Practice Name

Please specify an answer

GP Email

Please specify an answer

GP Phone number (if known)

Please enter a valid phone number

Which pharmacy will you use?

ℹ️ You need to nominate a nearby pharmacy where you can collect any medications we prescribe.

Pharmacy Name

Please specify an answer

Pharmacy Postcode

Please specify an answer

Pharmacy Email

Please specify an answer

Pharmacy Phone number (if known)

Please enter a valid phone number

Do you have a support person?

ℹ️ We usually require our clients to have a support person (friend or family member) who can be with them during detox week.

Support Person First Name

Please specify an answer

Support Person Surname

Please specify an answer

Support Person Email

Please specify an answer

Phone number (if known)

Please enter a valid phone number

Thank-you for that demographic information @first_name

Your Medical History

The next section of the form is for your detailed medical history.

AUDIT_Questionnaire

ℹ️ The Alcohol Use Disorders Identification Test (AUDIT) helps us to assess your behavioural and thinking patterns of drinking

How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often during the last year have you had 6 or more drinks on one occasion?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected of you because of your drinking?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy session?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or someone else been injured as a result of your drinking?

Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested you cut down?

Your AUDIT Score

Your clinician will discuss this with you, and what it means for your treatment. (A high or low AUDIT score is not a barrier to accessing treatment)

@AUDIT_Q1+@AUDIT_Q2+@AUDIT_Q3+@AUDIT_Q4+@AUDIT_Q5+@AUDIT_Q6+@AUDIT_Q7+@AUDIT_Q8+@AUDIT_Q8+@AUDIT_Q9+@AUDIT_Q10

SADQ_Questionnaire

ℹ️ The Severity of Alcohol Dependence Questionnaire (SADQ) helps us to assess your physical level of dependence to inform treatment

Please recall a typical period of heavy drinking in the last six months and note the month and year.

Please specify an answer

During that period of heavy drinking:

The day after drinking alcohol, I woke up feeling sweaty.

The day after drinking alcohol, my hands shook first thing in the morning.

The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't have a drink.

The day after drinking alcohol, I woke up absolutely drenched in sweat.

The day after drinking alcohol, I dread waking up in the morning.

The day after drinking alcohol, I was frightened of meeting people first thing in the morning.

The day after drinking alcohol, I felt at the edge of despair when I awoke.

The day after drinking alcohol, I felt very frightened when I awoke.

The day after drinking alcohol, I liked to have an alcoholic drink in the morning.

The day after drinking alcohol, I always gulped my first few alcoholic drinks down as quickly as possible.

The day after drinking alcohol, I drank more alcohol to get rid of the shakes.

The day after drinking alcohol, I had a very strong craving for a drink when I awoke.

I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers).

I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers).

I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers).

I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers).

Now imagine you have been completely off drink for a few weeks and then drink heavily for 2 days. How would you feel the morning after those 2 days?

I would start to sweat.

My hands would shake.

My body would shake.

I would be craving for a drink.

Your SADQ Score

Your clinician will discuss this with you, and what it means for your treatment. (These scores will inform clinical management, particularly if you are having a medicated detox with us.)

@SADQ_Q1+@SADQ_Q2+@SADQ_Q3+@SADQ_Q4+@SADQ_Q5+@SADQ_Q6+@SADQ_Q7+@SADQ_Q8+@SADQ_Q10+@SADQ_Q11+@SADQ_Q12+@SADQ_Q13+@SADQ_Q14+@SADQ_Q15+@SADQ_Q16+@SADQ_Q17+@SADQ_Q18+@SADQ_Q19+@SADQ_Q20

PHQ9_Questionnaire

ℹ️ The PHQ9 helps us to assess any current depression you may be experiencing, so we can track this together over time

Over the last 2 weeks, how often have you been bothered by any of the following:

Little interest or pleasure doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself in some way

Your PHQ9 Score

Your clinician will discuss this with you, and what it means for your treatment. (A high or low PHQ9 score is not a barrier to accessing treatment - you should expect to see this improve over time)

@PHQ9_1+@PHQ9_2+@PHQ9_3+@PHQ9_4+@PHQ9_5+@PHQ9_6+@PHQ9_7+@PHQ9_8+@PHQ9_9

GAD7_Questionnaire

ℹ️ The GAD7 helps us to assess any anxiety symptoms you may be experiencing, so we can track this together over time

Over the last 2 weeks, how often have you been bothered by any of the following:

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Your GAD7 Score

Your clinician will discuss this with you, and what it means for your treatment. (A high or low GAD7) score is not a barrier to accessing treatment - you should expect to see this improve over time)

@GAD7_1+@GAD7_2+@GAD7_3+@GAD7_4+@GAD7_5+@GAD7_6+@GAD7_7

Have you used any of the following in the past 4 weeks?

ℹ️ This helps us to understand any co-occurring substance issues you may be having so that we can tailor treatment accordingly

Have you been through an alcohol detox before?

ℹ️ This helps us to understand any previous treatment you've had so we can explore what did and didn't work

Please choose an option

Yes

Tell us a bit more about that detox?

ℹ️ This helps us to understand any previous treatment you've had so we can explore what did and didn't work

Please tell us when you last detoxed (MM-YYYY)

Please specify an answer

What medications did you take during detox?

Please specify an answer

Do you have any history of seizures, hallucinations or blackouts?

ℹ️ This helps us to understand any risks we need to be aware of in planning your treatment

Please select all that apply

Do you take any regular prescription medication?

ℹ️ This helps us to be aware of any potential interactions with medications we might prescribe

Please choose an option

Yes

Please list any prescribed medications you are currently taking

ℹ️ This helps us to be aware of any potential interactions with medications we might prescribe

Include the name of the medication, dosage and frequency

Please specify an answer

Have you had any major illness or operation?

ℹ️ This helps us to be aware of any risks rleated with previous surgeries or illnesses

Please choose an option

Yes

Please provide more details about your illness or operation?

ℹ️ This helps us to be aware of any potential interactions with medications we might prescribe

Please include details and dates

Please specify an answer

Is there a history of heavy use or dependence on alcohol or other substances in your family?

ℹ️ This helps us to tailor support to your circumstances

Please choose an option

Yes

Unsure

Have you had treatment for mental health concerns?

ℹ️ This helps us to tailor support to your specific circumstances

Please select all that apply

I have seen a mental health practitioner for my mental health

I have been prescribed medications for my mental health

I have been hospitalised for my mental health

I have a current mental health worker (psychiatrist, psychologist or therapist)

None of the above

Have you had any recent legal or housing challenges?

ℹ️ This helps us to manage any risks that may impact continuity of care with us

Please select all that apply

I have been homeless in the past 4 weeks

I have been at risk of eviction in the past 4 weeks

I have been arrested in the past 4 weeks

I have other social concerns I'd like to discuss

None of the above

MUST_Questionnaire

ℹ️ The Malnutrition Universal Screening Tool (MUST) helps us to identify any risks of malnutrition and determine what blood tests you might require

What is your current weight (in kg)

Please specify an answer

What is your current height (in cm)

Please specify an answer

What was your approximate weight (in kg) 3-6 months ago?

Please specify an answer

How is your current food intake?

The next few questions are about consent to how we use your data.

Use of Email and SMS

ℹ️ Please note that without this consent we are unable to provide services to you as a digital provider

I understand that Clean Slate Clinic Ltd may contact me by email or SMS in relation to my care and treatment (for example, appointment reminders, care instructions, or urgent service updates).

I acknowledge that while Clean Slate Clinic Ltd takes all reasonable steps to keep communications secure, email and SMS may not always be fully secure methods of communication.

I consent to being contacted by Email and SMS for correspondence relating to my care and services.

Signature

✕ Click here to sign

Marketing

ℹ️ We do not require this consent in order to provide treatment to you. Please click continue if you do not consent.

I consent to Clean Slate Clinic Ltd contacting me about new services, programs, or events that may be of interest to me.

I understand I can withdraw this consent at any time by contacting services.uk@cleanslateclinic.com, clicking 'unsubscribe' on any email or typing 'STOP' for SMS.

Signature

✕ Click here to sign

Liaising with your GP

ℹ️ Depending on your individual circumstances we may require consent to liaise with your GP in order to provide safe treatment to you. If you have any concerns with this, please click 'Continue' without signing and your clinician will discuss this further with you.

I consent to Clean Slate Clinic Ltd sharing relevant information about my care, treatment plan, prescriptions, and progress with my GP practice, and requesting relevant information from my GP.

Signature

✕ Click here to sign

Final question...!

Research & Service Improvement

ℹ️ We are committed to improving the treatment of substance use disorders in and beyond Clean Slate Clinic and value the opportunity to carry out research and service improvement. We do not require this consent in order to provide treatment to you.

I consent to my data being used anonymously for research, service evaluation, audit, and quality improvement purposes.

I understand my personal identity will not be disclosed.

Signature

✕ Click here to sign

Thank-you @first_name, we're all set!

We've received your assessment form and look forward to welcoming you to your first appointment.

Next Steps

Your clinician will review your answers
You'll receive appointment reminders by email and SMS
Find a quiet place to have your first clinician appointment
Congratulate yourself on taking this step to better health

How can I get in touch?

Call us on 0203 835 4705

Email services.uk@cleanslateclinic.com

What should I do before my appointment?

Take some time to reflect on why you've taken this step and what you'd like to achieve - this will help you to set the right goals with your clinician

Where can I find more information?

You can find lots more information and useful resources on our website www.cleanslateclinic.co.uk

Welcome - you're in the right place.

This comprehensive assessment (about 20–30 minutes) helps us understand your context and tailor care safely. A nurse will review your answers in advance of your booked appointment and discuss them with you.

Use the arrows to move forward/back — your progress auto-saves if you leave and return. Your information is confidential and only seen by our care team.

What is your legal name?

What is your address?

What type of accommodation is this?

Can we send packages to this address?

What address can we use?

What is your gender?

Are you pregnant?

What is your ethnicity?

Do you face additional barriers to accessing care?

Have you been a primary caregiver or living with children in the past 4 weeks?

What is your current employment status?

What is your occupation?

How many days have you been @Employment-Status in the past 4 weeks?

Who is your GP?

Which pharmacy will you use?

Do you have a support person?

Your Medical History

AUDIT_Questionnaire

Your AUDIT Score

@AUDIT_Q1+@AUDIT_Q2+@AUDIT_Q3+@AUDIT_Q4+@AUDIT_Q5+@AUDIT_Q6+@AUDIT_Q7+@AUDIT_Q8+@AUDIT_Q8+@AUDIT_Q9+@AUDIT_Q10

SADQ_Questionnaire

Your SADQ Score

@SADQ_Q1+@SADQ_Q2+@SADQ_Q3+@SADQ_Q4+@SADQ_Q5+@SADQ_Q6+@SADQ_Q7+@SADQ_Q8+@SADQ_Q10+@SADQ_Q11+@SADQ_Q12+@SADQ_Q13+@SADQ_Q14+@SADQ_Q15+@SADQ_Q16+@SADQ_Q17+@SADQ_Q18+@SADQ_Q19+@SADQ_Q20

PHQ9_Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following:

Your PHQ9 Score

@PHQ9_1+@PHQ9_2+@PHQ9_3+@PHQ9_4+@PHQ9_5+@PHQ9_6+@PHQ9_7+@PHQ9_8+@PHQ9_9

GAD7_Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following:

Your GAD7 Score

@GAD7_1+@GAD7_2+@GAD7_3+@GAD7_4+@GAD7_5+@GAD7_6+@GAD7_7

Have you used any of the following in the past 4 weeks?

Have you been through an alcohol detox before?

Tell us a bit more about that detox?

Do you have any history of seizures, hallucinations or blackouts?

Do you take any regular prescription medication?

Please list any prescribed medications you are currently taking

Have you had any major illness or operation?

Please provide more details about your illness or operation?

Is there a history of heavy use or dependence on alcohol or other substances in your family?

Have you had treatment for mental health concerns?

Have you had any recent legal or housing challenges?

MUST_Questionnaire

How would you self-assess your current wellbeing?

Use of Email and SMS

Marketing

Liaising with your GP

Research & Service Improvement

Thank-you @first_name, we're all set!

We've received your assessment form and look forward to welcoming you to your first appointment.

Next Steps

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