Relationship to you (your GP etc): Phone no: Agency/Service: There are GLBTI (Gay/Lesbian/Bisexual/Trans/Intersex) specific Alcohol and Drug Services available. Would this be of interest to you? Yes No SOME MORE INFORMATION YOU Are you employed? Yes No How many days of paid work (not including voluntary work) have you had in the past four weeks? If not employed, what type of benefit do you receive? How many days of school, tertiary education, vocational training have you had in the past four If you gamble are you concerned about your gambling? Yes No I don’t gamble at all Are you currently receiving support for any gambling issues? Yes No Have you been arrested in the past four weeks? Yes No Do you have any current/pending issues? Yes No Are you currently receiving support for any issues? Yes No What type of accommodation do you live in: Private rental Public rental Boarding house Own home Homeless Couch surfing Have you been homeless in the past four Yes No Have you been at risk of eviction in the past four weeks? Yes No Do you live in a place where you feel safe? Yes No If no please briefly explain in the space below: Details: Are you currently receiving any support for any housing issues? Yes No Are you pregnant? Yes No Who do you currently live with? Family Friends Alone Out of Home care Other Have you, at any time in the past four weeks, been a primary caregiver for or living with any child/children? Yes No How old are each of the children you care for? (please write ages in the boxes below starting with the youngest child) 1. Youngest 2. Next oldest child 3. Next oldest child 4. Next oldest child 5. Next oldest 6. Next oldest child 7. Next oldest 8. Next oldest 9. Next oldest child 10.Next oldest child How would you rate your psychological health status in the past four weeks (eg anxiety, depression and problem emotions and feelings)? How would you rate your physical health status in the past four weeks (e.g extent of physical symptoms and bothered by illness)? How would you rate your overall quality of life in the past four weeks (e.g. able to enjoy life, satisfied with living conditions)?
Relationship to you (your GP etc): Phone no: Agency/Service: There are GLBTI (Gay/Lesbian/Bisexual/Trans/Intersex) specific Alcohol and Drug Services available. Would this be of interest to you? Yes No SOME MORE INFORMATION YOU Are you employed? Yes No How many days of paid work (not including voluntary work) have you had in the past four weeks? If not employed, what type of benefit do you receive? How many days of school, tertiary education, vocational training have you had in the past four If you gamble are you concerned about your gambling? Yes No I don’t gamble at all Are you currently receiving support for any gambling issues? Yes No Have you been arrested in the past four weeks? Yes No Do you have any current/pending issues? Yes No Are you currently receiving support for any issues? Yes No What type of accommodation do you live in: Private rental Public rental Boarding house Own home Homeless Couch surfing Have you been homeless in the past four Yes No Have you been at risk of eviction in the past four weeks? Yes No Do you live in a place where you feel safe? Yes No If no please briefly explain in the space below: Details: Are you currently receiving any support for any housing issues? Yes No Are you pregnant? Yes No Who do you currently live with? Family Friends Alone Out of Home care Other Have you, at any time in the past four weeks, been a primary caregiver for or living with any child/children? Yes No How old are each of the children you care for? (please write ages in the boxes below starting with the youngest child) 1. Youngest 2. Next oldest child 3. Next oldest child 4. Next oldest child 5. Next oldest 6. Next oldest child 7. Next oldest 8. Next oldest 9. Next oldest child 10.Next oldest child How would you rate your psychological health status in the past four weeks (eg anxiety, depression and problem emotions and feelings)? How would you rate your physical health status in the past four weeks (e.g extent of physical symptoms and bothered by illness)? How would you rate your overall quality of life in the past four weeks (e.g. able to enjoy life, satisfied with living conditions)?