<p> 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:</p><p>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)</p><p>Do you consent to us sharing information with this person?  Yes  No Children & Families: Do you have contact with children? Yes No </p><p>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</p><p>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</p><p>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</p><p>Are any of your children young carers? Yes No</p><p>If pregnant/partner pregnant what is the expected date of delivery:</p><p> cgl/fd/211; Version 1.1a; Date: March 2017 Page 1 of 4 OFFICIAL -SENSITIVE GP Details Doctor:</p><p>Surgery:</p><p>Address:</p><p> 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:</p><p>How do you use: Inject Sniff Smoke Oral Other </p><p>How often do you use? </p><p>How much do you use?</p><p>How much do you spend a week on this substance? Date last used:</p><p>Second substance of choice: Age First Used:</p><p>How do you use: Inject Sniff Smoke Oral Other </p><p>How often do you use? </p><p>How much do you use?</p><p>How much do you spend a week on this substance? Date last used:</p><p>Third substance of choice: Age First Used:</p><p>How do you use: Inject Sniff Smoke Oral Other </p><p>How often do you use? </p><p>How much do you use?</p><p>How much do you spend a week on this substance? Date last used:</p><p>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:</p><p>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:</p><p>Injecting: Have you ever injected drugs:  Never injected  Previously injected  Currently inject </p><p>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.’</p><p>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</p>