Have you ever had to leave an apartment, shelter program, or Yes No Refused other place you were staying because of your physical health? Do you have any chronic health issues with your liver, kidneys, Yes No Refused stomach, lungs or heart? If there was space available in a program that specifically assists people that live with HIV or AIDS, would that be of Yes No Refused interest to you? Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live Yes No Refused independently because you’d need help? When you are sick or not feeling well, do you avoid getting Yes No Refused help? Are you currently pregnant, have you ever been pregnant, or Yes No Refused have you ever gotten someone pregnant? SCORE If “yes” to any of the above, SCORE 1 for Physical Health Has your drinking or drug use led you to being *kicked out of an* Yes No Refused apartment or program where you were staying in the past? “asked * or forces to leave” Will drinking or drug use make it difficult for you to stay Yes No Refused housed or afford your housing? If you’ve ever used marijuana, did you ever try is at age 12 or Yes No Refused younger? *Did you ever use marijuana at age 12 or younger? SCORE If “yes” to any of the above, then SCORE 1 for Substance Use. Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of: A mental health or concern? Yes No Refused A past head injury? Yes No Refused A learning disability, developmental disability, or other Yes No Refused impairment? Do you have any mental health or brain issues that would make it hard for you to live independently because you’d need Yes No Refused help? SCORE If yes to any of the above, then SCORE 1 for Mental Health If the respondent scored 1 for Physical Health AND 1 for Substance Use AND 1
Have you ever had to leave an apartment, shelter program, or other place you were staying because of your physical health? Yes No Refused Do you have any chronic health issues with your liver, kidneys, stomach, lungs or heart? Yes No Refused If there was space available in a program that specifically assists people that live with HIV or AIDS, would that be of interest to you? Yes No Refused Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live independently because you’d need help? Yes No Refused When you are sick or not feeling well, do you avoid getting help? Yes No Refused Are you currently pregnant, have you ever been pregnant, or have you ever gotten someone pregnant? Yes No Refused If “yes” to any of the above, SCORE 1 for Physical Health SCORE Has your drinking or drug use led you to being *kicked out of an* apartment or program where you were staying in the past? * “asked or forces to leave” Yes No Refused Will drinking or drug use make it difficult for you to stay housed or afford your housing? Yes No Refused If you’ve ever used marijuana, did you ever try is at age 12 or younger? *Did you ever use marijuana at age 12 or younger? Yes No Refused If “yes” to any of the above, then SCORE 1 for Substance Use. SCORE Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of: A mental health or concern? Yes No Refused A past head injury? Yes No Refused A learning disability, developmental disability, or other impairment? Yes No Refused Do you have any mental health or brain issues that would make it hard for you to live independently because you’d need help? Yes No Refused If yes to any of the above, then SCORE 1 for Mental Health SCORE If the respondent scored 1 for Physical Health AND 1 for Substance Use AND 1
VI-SPDAT-MN-Youth_LockedFillable.docx