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First Name
Last Name
Nickname
Gender
Select your option...
Male
Female
-
Agender
Androgyne
Androgynous
Bigender
Cis
Cis Man
Cis Woman
Gender Fluid
Gender Nonconforming
Gender Questioning
Gender Variant
Genderqueer
Intersex
Neutrois
Non-binary
Pangender
Transgender
Transgender (Man)
Transgender (Woman)
Ethnicity
Select your option...
Asian British
Asian Other
Bangladeshi
Black African
Black British
Black Caribbean
Black Other
Chinese
Indian
Mixed Other/Multiple Ethnic Background
Not Stated
Pakistani
Polish
Portuguese
White Welsh
White British
White Irish
White Other
DOB
NHS Number
Address
Postcode
Area
Select your option...
Rhondda
Cynon
Taff
Merthyr Tydfil
Bridgend
Out of Area
Who do you live with
How can you be contacted?
Letter
Telephone
SMS
Email
Which methods of contact are acceptable by the Service User?
Where would you prefer appointments?
Office
Home
Community
Where is the service user happy to have appointments? - Please tick all that apply
Telephone
Mobile
Email
Employment Status
Select your option...
In regular employment
Registered pupil/student
Economically inactive
Unemployed and not seeking work
Unemployed and seeking work
Armed Services Veteran
Yes
No
Primary Substance
Select your option...
Alcohol
Amphetamine
Anabolic Steroids
Buvidal
Cannabis
Cocaine
Codeine Tablets
Crack
Ecstacy/MDMA
Gabapentin
Heroin
Ketamin
Methadone
NPS
Opiate Other
Pregablin
Solvents
Spice
Subutex
Tramadol
Valium/MSJ/Diazepam
-
No Substance
If no substance, add more information into notes above
How Often
Select your option...
Daily
2-3 Times a Week
3-5 Times a Week
Weekly
Fortnightly
Monthly
Varies
Abstinent
Binge
Amount
Are you pregnant
Yes
No
Unsure
Physical and/or mental health problems
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