Cgl/Fd/211; Version 1.1A; Date: March 2017 Page 1 of 4
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Welcome to change, grow, live Language: Do you require an interpreter? Yes No Do you require support through a British Sign Language Interpreter? Yes No Disability: Do you consider yourself to have a disability? Yes No If yes please provide details:
Employment Status: Long term illness Accommodation Status: Regular employment Ex Armed Services Problem with Housing Student Current Armed Services No housing problem Unpaid work (voluntary) Unemployed (receiving no benefits) Homeless Homemaker Unemployed (seeking work) Please provide details: Retired Other Time since last paid employment: Less than 1 year 2- 3 years Currently employed Never employed 1 – 2 years 3+ years (if 3+, please state number: ____) Prefer not to say Smoking Status: Currently pregnant: Yes No Unsure Current Previous Never Partner currently pregnant: Yes No Unsure Next of Kin: (we will only contact this person in a case of an emergency)
Do you consent to us sharing information with this person? Yes No Children & Families: Do you have contact with children? Yes No
Number of children under 5 years old: Please record names and dates of birth of ALL children and details of the primary carer: Name Date of Birth Primary carer
Parental Status Not a parent None of my children live with me Some of my children live with me All of my children live with me Children stay with me at least one night a week
Location of children you are a parent to: Live with you Live with your partner Live with you and your partner Live with your ex-partner Live with Grandparents In care – no contact In care – regular contact, supervised In care- regular contact, unsupervised Live with other family Other
Are any of your children young carers? Yes No
If pregnant/partner pregnant what is the expected date of delivery:
cgl/fd/211; Version 1.1a; Date: March 2017 Page 1 of 4 OFFICIAL -SENSITIVE GP Details Doctor:
Surgery:
Address:
cgl/fd/211; Version 1.1a; Date: March 2017 Page 2 of 4 OFFICIAL -SENSITIVE Drug and/or Alcohol Use Main substance of choice: Age First Used:
How do you use: Inject Sniff Smoke Oral Other
How often do you use?
How much do you use?
How much do you spend a week on this substance? Date last used:
Second substance of choice: Age First Used:
How do you use: Inject Sniff Smoke Oral Other
How often do you use?
How much do you use?
How much do you spend a week on this substance? Date last used:
Third substance of choice: Age First Used:
How do you use: Inject Sniff Smoke Oral Other
How often do you use?
How much do you use?
How much do you spend a week on this substance? Date last used:
Do you use Novel Psychoactive Substances (Legal/Illegal Do you use any volatile substances? (Gas, Glue, Aerosols) Highs) Yes Yes No No Previously Previously If yes please list: If yes please list:
Do you use Steroids or any other image/performance Do you use any over the counter medications (such as Co- enhancing drugs? codamol, Paracetamol)? Yes Yes No No Previously Previously If yes please list: If yes please list:
Injecting: Have you ever injected drugs: Never injected Previously injected Currently inject
If you have previously injected drugs: At what age did you first inject? Have you injected in the last 28 days? Yes No Have you ever shared injecting equipment? Yes No Have you shared injecting equipment in last 28 days? Yes No Have you ever allowed someone else to inject you? Yes No Criminal Justice: Are you currently working with Criminal Justice Services (e.g. Police, National Probation Service, Community Rehabilitation Companies, Prisons)? Yes No If no please go to next section ‘Referrer details.’
If yes, what prompted the contact? cgl/fd/211; Version 1.1a; Date: March 2017 Page 3 of 4 RequiredOFFICIAL -SENSITIVEAssessment Imposed Following Positive Drug Test Conditional Cautioning Pre-Sentence Report