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CHAT Tool - Offender Health Research Network

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Tick No or Yes as appropriate for each question and include additional notes No Yes<br />

Was your offence against a family member<br />

Do you have any problems with dependence on drugs/alcohol (check substance<br />

misuse part of the <strong>CHAT</strong>)<br />

Have you ever tried to take your own life<br />

If yes, what happened<br />

Do you sometimes think of taking your own life<br />

If yes: - how often E.g. more than once a day, once a day, once a week<br />

Surname:<br />

DOB:<br />

Forenames:<br />

NHS Number:<br />

<strong>CHAT</strong> <strong>Tool</strong> Secure Estate (Version 3 - June 2013)<br />

68 | P age

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