here to completed Yes No DD/MM/YYYY / / Question #5 SCORE: 17 YOUNGER, THEN SCORE 1. A. History of Housing and Homelessness do you sleep most frequently? (check one) Surfing (specify): 1. Refused How long has it been since you lived in permanent stable housing? Refused In the last year, how many times have you been homeless? (Use Q#3 Answer from Ontario Questions) 6 3+ 1. B. Risks In the past six months, how many times have you... Received health care at an emergency department/room? Refused Taken an ambulance to the hospital? Refused Been hospitalized as an inpatient? Refused Used a crisis service, including sexual assault crisis, mental Refused health crisis, family/intimate violence, distress centers and
here to completed Question #5 DD/MM/YYYY / / Yes No 17 YOUNGER, 1. A. History of Housing and Homelessness do you sleep most frequently? (check one) Surfing (specify): 1. How long has it been since you lived in permanent stable housing? Refused In the last year, how many times have you been homeless? (Use Q#3 Answer from Ontario Questions) Refused 6 3+ 1. B. Risks In the past six months, how many times have you... Received health care at an emergency department/room? Refused Taken an ambulance to the hospital? Refused Been hospitalized as an inpatient? Refused Used a crisis service, including sexual assault crisis, mental health crisis, family/intimate violence, distress centers and Refused THEN SCORE SCORE:
TAY-VI-SPDAT-V1-20K-RW-ONTARIO-ONLY-1.docx